Apparent heparin resistance from elevated factor VIII during pregnancy

Raschke, Robert; Guidry, James R.; Foley, Michael R.

doi:10.1016/s0029-7844(00)01053-x

Cited by 24 publications

(9 citation statements)

References 7 publications

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“…69,71 With heparin levels of 0.3 to 0.7 anti-Xa units/mL, modern aPTT reagents and coagulometers produce aPTT ratios that range from 1.6-2.7 to 3.7-6.2 times control. [67][68][69][70][71][72][74][75][76][77][78][79][80][81] Although various heparin dose-adjustment nomograms have been developed ( Table 3 65 ), none is applicable to all aPTT reagents. 71 For these reasons, the therapeutic aPTT range at a particular institution should be adapted to the responsiveness of the reagent and coagulometer used.…”

Section: Limitations Of Heparinmentioning

confidence: 99%

Parenteral Anticoagulants

García

Baglin

Weitz

et al. 2012

Chest

893

480

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This article describes the pharmacology of approved parenteral anticoagulants. These include the indirect anticoagulants, unfractionated heparin (UFH), low-molecular-weight heparins (LMWHs), fondaparinux, and danaparoid, as well as the direct thrombin inhibitors hirudin, bivalirudin, and argatroban. UFH is a heterogeneous mixture of glycosaminoglycans that bind to antithrombin via a unique pentasaccharide sequence and catalyze the inactivation of thrombin, factor Xa, and other clotting enzymes. Heparin also binds to cells and plasma proteins other than antithrombin causing unpredictable pharmacokinetic and pharmacodynamic properties and triggering nonhemorrhagic side effects, such as heparin-induced thrombocytopenia (HIT) and osteoporosis. LMWHs have greater inhibitory activity against factor Xa than thrombin and exhibit less binding to cells and plasma proteins than heparin. Consequently, LMWH preparations have more predictable pharmacokinetic and pharmacodynamic properties, have a longer half-life than heparin, and are associated with a lower risk of nonhemorrhagic side effects. LMWHs can be administered once daily or bid by subcutaneous injection, without coagulation monitoring. Based on their greater convenience, LMWHs have replaced UFH for many clinical indications. Fondaparinux, a synthetic pentasaccharide, catalyzes the inhibition of factor Xa, but not thrombin, in an antithrombin-dependent fashion. Fondaparinux binds only to antithrombin. Therefore, fondaparinux-associated HIT or osteoporosis is unlikely to occur. Fondaparinux exhibits complete bioavailability when administered subcutaneously, has a longer half-life than LMWHs, and is given once daily by subcutaneous injection in fixed doses, without coagulation monitoring. Three additional parenteral direct thrombin inhibitors and danaparoid are approved as alternatives to heparin in patients with HIT.

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Section: Limitations Of Heparinmentioning

confidence: 99%

Parenteral Anticoagulants

García

Baglin

Weitz

et al. 2012

Chest

893

480

View full text Add to dashboard Cite

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“…These patients have a downward shift in the dose response curve resulting in a shortened or blunted aPTT response. Such patients may appear to be heparin resistant but increasing the heparin dose based upon the aPTT may lead to over-anticoagulation and an increased risk of bleeding [ 34 ].…”

Section: Guidancementioning

confidence: 99%

Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism

Smythe

Priziola

Dobesh

et al. 2016

J Thromb Thrombolysis

188

183

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Venous thromboembolism (VTE) is a serious and often fatal medical condition with an increasing incidence. Despite the changing landscape of VTE treatment with the introduction of the new direct oral anticoagulants many uncertainties remain regarding the optimal use of traditional parenteral agents. This manuscript, initiated by the Anticoagulation Forum, provides clinical guidance based on existing guidelines and consensus expert opinion where guidelines are lacking. This specific chapter addresses the practical management of heparins including low molecular weight heparins and fondaparinux. For each anticoagulant a list of the most common practice related questions were created. Each question was addressed using a brief focused literature review followed by a multidisciplinary consensus guidance recommendation. Issues addressed included initial anticoagulant dosing recommendations, recommended baseline laboratory monitoring, managing dose adjustments, evidence to support a relationship between laboratory tests and meaningful clinical outcomes, special patient populations including extremes of weight and renal impairment, duration of necessary parenteral therapy during the transition to oral therapy, candidates for outpatient treatment where appropriate and management of over-anticoagulation and adverse effects including bleeding and heparin induced thrombocytopenia. This article concludes with a concise table of clinical management questions and guidance recommendations to provide a quick reference for the practical management of heparin, low molecular weight heparin and fondaparinux.

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“…Therefore, subcutaneous UFH is very difficult to use to achieve therapeutic anticoagulation. 30,31 The 2008 ACCP guideline suggested that it is uncertain if adjustment of heparin dose in response to the aPTT or heparin levels improves efficacy or safety. 32 Another study of pregnant women on UFH showed that up to one-third of these women lost bone mass during treatment.…”

Section: Discussionmentioning

confidence: 99%

Comparison of Continuation of Low-Molecular-Weight Heparin versus Switching to Unfractionated Heparin in the Peripartum

2019

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Objective This study aimed to determine whether switching from low-molecular-weight heparin (LMWH) to unfractionated heparin (UFH) or its continuation in the peripartum affected anesthesia choice or bleeding complications. Study Design A retrospective cohort study of 189 anticoagulated pregnant women who delivered at the University of Illinois at Chicago Hospital and Health Science System from 2005 to 2016. Demography, anesthesia choice, and bleeding complications were compared between the two groups. Results There were 138 (73%) women on LMWH versus 51 (27%) who switched from LMWH to UFH during the peripartum. The demographics were similar, 123 women were on prophylactic: 81 (66%) were on LMWH and 42 (34%) switched to UFH. Of the 66 women on therapeutic anticoagulation, 57 (86%) continued on LMWH, while 9 (14%) switched to UFH. No difference in neuraxial anesthesia type received: 42 (82.4%) versus 108 (79.7%) women (odds ratio: 1.20, 95% confidence interval [CI]: 0.52–2.73, p = 0.837). Bleeding complications more than 1,000 mL, 6 versus 10% (relative risk [RR]: 0.58, 95% CI: 0.17–1.94, p = 0.380) and relaparotomy due to hemoperitoneum, 2% in either group (RR: 0.9, 95% CI: 0.10–8.48, p = 0.930) were similar in the two groups regardless of time of last injection. Conclusion Anesthesia type and rate of bleeding complications were similar between women on LMWH and UFH during the peripartum.

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Apparent heparin resistance from elevated factor VIII during pregnancy

Cited by 24 publications

References 7 publications

Parenteral Anticoagulants

Parenteral Anticoagulants

Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism

Comparison of Continuation of Low-Molecular-Weight Heparin versus Switching to Unfractionated Heparin in the Peripartum

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