1 Heparin Induced Thrombocytopenia - Adult - Inpatient External Clinical Practice Guideline Endorsement Note: Active Table of Contents – Click each header below to jump to the section of interest Table of Contents INTRODUCTION .................................................................................................................................3 SCOPE ................................................................................................................................................3 REFERENCES ......................................................................................................................................5 Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 Effective 06-16-2022. Contact CCKM@uwhealth.org for previous versions. 2 Content Expert(s): Name: Anne Rose, PharmD - Pharmacy; Anticoagulation Stewardship Phone Number: (608) 263-9738 Email Address: arose@uwhealth.org Contact for Changes: Name: Philip Trapskin, PharmD, BCPS – Drug Policy Program Phone Number: (608) 263-1328 Email Address: ptrapskin@uwhealth.org Guideline Author(s): Anne Rose, PharmD – Pharmacy: Anticoagulation Stewardship Workgroup Members: John Hoch, MD- Dept. of Surgery- Vascular Surgery Kraig Kumfer, MD- Dept. of Medicine- Hospitalists Erin Robinson, PharmD – Dept. of Pharmacy- Drug Policy Program Anne Rose, PharmD- Dept. of Pharmacy- Anticoagulation Stewardship John Sheehan, MD – Dept. of Medicine- Oncology Eliot Williams, MD – Dept. of Medicine- Oncology Luke Zurbriggen, MD- Dept. of Medicine Education (Hematology/Oncology) Reviewer(s): Anticoagulation Subcommittee Committee Approval(s): Anticoagulation Subcommittee (11/9/2020, 5/9/22) Pharmacy & Therapeutics Committee (12/17/2020, 6/16/22) Plan for Review: The guideline will be routinely reviewed once every three years. Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 Effective 06-16-2022. Contact CCKM@uwhealth.org for previous versions. 3 Introduction UW Health has agreed to endorse the American Society of Hematology 2018 Guidelines for the Management of Venous Thromboembolism: Heparin Induced Thrombocytopenia (HIT) with additional recommendations for transitioning from anticoagulation from the parenteral to the enteral route of administration The ASH guideline workgroup developed and graded the recommendations and assessed the certainty of the supporting evidence by following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Development of the guideline was entirely funded by ASH. Conflict of interest disclosure was provided by all workgroup members. At the time of appointment to the workgroup, the majority of members, including the chair and vice chair, had no conflict of interest. The guideline development process and the quality of reporting was assessed by two UW Health appraisers. The purpose of the appraisal was to validate the rigor of the guideline development process and transparency of the resulting recommendations. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used to complete the assessment. https://www.agreetrust.org/ The ASH guideline meets all of the criteria recommended by AGREE to ensure a rigorous synthesis of all available evidence. As recommended, transparent methods are used to control conflict of interest among workgroup members and to control bias in collecting, combining, and interpreting the evidence. ASH also meets standards for presenting unambiguous recommendations and by including external stakeholders in the final review. Scope • The clinical practice guideline provides recommendations for best practices to diagnose and manage HIT in adult patients. Recommendations address screening of asymptomatic patients, diagnosis and initial management of patients with suspected HIT, treatment of acute HIT, and management of HIT in special situations including cardiovascular surgery, percutaneous cardiovascular interventions, renal replacement therapy, and venous thromboembolism prophylaxis. • Intended users of the guideline at UW Health are physicians, advanced practice providers, pharmacists, and nurses. Disclaimer Clinical practice guidelines assist clinicians by providing a framework for the evaluation and treatment of patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem. Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 Effective 06-16-2022. Contact CCKM@uwhealth.org for previous versions. 4 Conflicts of Interest Workgroup members declared conflicts which may influence decision making. Collateral Tools & Resources The following collateral tools and resources support staff execution and performance of the evidence-based guideline recommendations in everyday clinical practice. Guideline Metrics 1. VTE Performance Measure – VTE 4 – UFH with dosage and platelet monitored by protocol 2. Frequency for HIT laboratory testing and false positive ELISA HIT results 3. Time to platelet count recovery 4. Thrombotic event rate Order Sets & Smart Sets 1. IP – HIT (Heparin Induced Thrombocytopenia) Adult – Supplemental – Order Set [3596] Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 Effective 06-16-2022. Contact CCKM@uwhealth.org for previous versions. 5 References 1. Cuker A, Arepally GM, Chong BH, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv. Nov 27 2018;2(22):3360-3392. doi:10.1182/bloodadvances.2018024489 2. Linkins LA, Dans AL, Moores LK, et al. Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012;141(2 Suppl):e495S-e530S. doi:10.1378/chest.11-2303 3. Argatroban injection [prescribing information]. Hospira, Inc.; Lake Forest, IL. 2019. 4. Verme-Gibboney CN, Hursting MJ. Argatroban dosing in patients with heparin-induced thrombocytopenia. Ann Pharmacother. Jul-Aug 2003;37(7-8):970-5. doi:10.1345/aph.1C443 5. Dager WE, Dougherty JA, Nguyen PH, Militello MA, Smythe MA. Heparin-induced thrombocytopenia: treatment options and special considerations. Pharmacotherapy. Apr 2007;27(4):564-87. doi:10.1592/phco.27.4.564 6. Kiser TH, Fish DN. Evaluation of bivalirudin treatment for heparin-induced thrombocytopenia in critically ill patients with hepatic and/or renal dysfunction. Pharmacotherapy. Apr 2006;26(4):452-60. doi:10.1592/phco.26.4.452 7. Kiser TH, Burch JC, Klem PM, Hassell KL. Safety, efficacy, and dosing requirements of bivalirudin in patients with heparin-induced thrombocytopenia. Pharmacotherapy. Sep 2008;28(9):1115- 24. doi:10.1592/phco.28.9.1115 8. Runyan CL, Cabral KP, Riker RR, et al. Correlation of bivalirudin dose with creatinine clearance during treatment of heparin-induced thrombocytopenia. Pharmacotherapy. Sep 2011;31(9):850- 6. doi:10.1592/phco.31.9.850 9. Tsu LV, Dager WE. Bivalirudin dosing adjustments for reduced renal function with or without hemodialysis in the management of heparin-induced thrombocytopenia. Ann Pharmacother. Oct 2011;45(10):1185-92. doi:10.1345/aph.1Q177 10. Wisler JW, Washam JB, Becker RC. Evaluation of dose requirements for prolonged bivalirudin administration in patients with renal insufficiency and suspected heparin-induced thrombocytopenia. J Thromb Thrombolysis. Apr 2012;33(3):287-95. doi:10.1007/s11239-011- 0677-3 11. Gosselin RC, Dager WE, King JH, et al. Effect of direct thrombin inhibitors, bivalirudin, lepirudin, and argatroban, on prothrombin time and INR values. Am J Clin Pathol. Apr 2004;121(4):593-9. doi:10.1309/D79K-4YG7-8NTN-YY38 12. Dang CH, Durkalski VL, Nappi JM. Evaluation of treatment with direct thrombin inhibitors in patients with heparin-induced thrombocytopenia. Pharmacotherapy. Apr 2006;26(4):461-8. doi:10.1592/phco.26.4.461 13. Kiser TH, Mann AM, Trujillo TC, Hassell KL. Evaluation of empiric versus nomogram-based direct thrombin inhibitor management in patients with suspected heparin-induced thrombocytopenia. Am J Hematol. Mar 2011;86(3):267-72. doi:10.1002/ajh.21955 14. Skrupky LP, Smith JR, Deal EN, et al. Comparison of bivalirudin and argatroban for the management of heparin-induced thrombocytopenia. Pharmacotherapy. Dec 2010;30(12):1229- 38. doi:10.1592/phco.30.12.1229 15. Fondaparinux (Arixtra®) [prescribing information]. GlaxoSmithKline; Research Triangle Park, NC. 2008. 16. Dabigatran (Pradaxa®) [prescribing information]. Boehringer Ingelheim Pharmaceuticals; Ridgefield, CT. 2015. Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 Effective 06-16-2022. Contact CCKM@uwhealth.org for previous versions. 6 17. Rivaroxaban (Xarelto®) [prescribing information]. Boehringer Ingelheim Pharmaceuticals; Ridgefield, CT. 2015. 18. Mirdamadi A. Dabigatran, a direct thrombin inhibitor, can be a life-saving treatment in heparin- induced thrombocytopenia. ARYA Atheroscler. Jan 2013;9(1):112-4. 19. Hellerslia V, Mehta P. Transition of anticoagulants.: Thomas Land Publishers; 2019. Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 06/2022 Effective 06-16-2022. Contact CCKM@uwhealth.org for previous versions.