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Lepirudin Appropriate in Heparin-Induced Thrombocytopenia
Although there have been cases of fatal anaphylactic reactions temporally related to IV lepirudin exposure, this should not preclude its use in patients with heparin-induced thrombocytopenia (HIT), researchers report in the April issue of the Mayo Clinic Proceedings.
Drs. Gustavo A. Cardenas and Steven R. Deitcher of the Cleveland Clinic Foundation, Ohio note that the 30-day risk of thrombosis may be greater than 50% in patients with HIT managed with heparin discontinuation alone. For these patients, anticoagulation with a direct thrombin inhibitor, such as lepirudin, is indicated.
However, a recent European report cited seven cases of severe anaphylactic reactions following use of lepirudin. Of those, six occurred after re-exposure and five patients died. There have also been other sporadic reports of allergic reactions following bolus administration of lepirudin.
To determine whether severe reactions are associated with lepirudin use, the researchers examined records at their institution covering more than 3 years; they identified 43 patients. All had undergone at least two courses of lepirudin therapy separated by at least 1 week.
Altogether, 10 patients had a systolic blood pressure drop of 20 mm Hg or higher on the first day of administration. Four patients had systolic blood pressures lower than 100 mm Hg (three of these four subjects had low systolic pressure at baseline). However, no cases of lepirudin-related allergic reactions or anaphylaxis were seen.
The researchers conclude that isolated and uncommon cases of anaphylaxis should not rule out use of the drug. "The risk appears to be particularly overshadowed by the benefit with regard to thrombosis, limb loss and death prevention in acute HIT," they add.