Therapeutic plasma exchange and intravenous immune globulin in the treatment of heparin‐induced thrombocytopenia: A systematic review

Abstract

Background: Immunomodulatory strategies in heparin-induced thrombocytopenia (HIT) include the use of intravenous immune globulin (IVIG) and therapeutic plasma exchange (TPE). The optimal application of these therapies is unknown and outcomes data are limited. We investigated treatment categories and laboratory and clinical outcomes of IVIG and/or TPE in HIT with a systematic literature review. Study Design and Methods: We searched MEDLINE, Embase, and Web of Science through December 2019 for studies combining controlled vocabulary and keywords related to thrombocytopenia, heparin, TPE, and IVIG. The primary outcome was treatment indication. Secondary outcomes were platelet recovery, HIT laboratory parameters, heparin re-exposure, and post-treatment course. Case-level data were analyzed by qualitative synthesis. Results: After 4241 references were screened, we identified 60 studies with four main categories of IVIG and/or TPE use as follows: (a) treatment of refractory HIT (n = 35; 31%); (b) initial therapy (n = 45; 40%); (c) cardiopulmonary bypass surgery (CPB; n = 30; 27%); and (d) other (n = 2; 2%). IVIG was most commonly used for the treatment of refractory HIT while TPE was primarily used to facilitate heparin exposure during CPB. Both IVIG and TPE were

Heparin-Induced Thrombocytopenia: A Review of New Concepts in Pathogenesis, Diagnosis, and Management

“…Alternative anticoagulation contraindicated [73,79] 3. Clinical course worsening despite non-heparin anticoagulation [72] 1. Clinical course worsening despite non-heparin anticoagulation [74,80] 2. aHIT [74,80] 3.…”

“…Cost; infectious, metabolic complications; difficulty in predicting how often and how long to perform [72,73] Adjunctive to anticoagulation, high cost, standard dose insufficient in severe cases…”

“…Additionally, although a single TPE removes about two-thirds of the HIT antibodies [71], the exact number of required plasma exchanges in order to effectively lower the plasmatic HIT antibodies concentration and the duration of action of TPE due to mobilization of the extravascular antibody compartment remain unknown and difficult to predict. Thus, TPE is probably best guided by biological monitoring [72,73]. TPE has been described as an effective option for managing HIT in three particular situations [72].…”

“…Thus, TPE is probably best guided by biological monitoring [72,73]. TPE has been described as an effective option for managing HIT in three particular situations [72]. First, pre/perioperative plasmapheresis along with intraoperative heparin anticoagulation is one of the three management options for patients with acute HIT or persisting positive functional assay and anti-PF4/H antibodies who require immediate cardiovascular surgery [48].…”

“…The third situation is when HIT clinical and biological course worsens/does not improve under well-conducted non-heparin anticoagulation (i.e., refractory HIT). For further details, we refer the reader to the recent excellent review of Onuoha et al [72].…”