Acute Thrombocytopenia after Administration of Heparin and Tirofiban:
Differential Diagnosis and Treatment

Thrasivoulos      Konstantinou; Evangelos      Sdogkos; Ioannis      Vogiatzis

doi:10.2174/04666230308141033

Abstract

Introduction: Drug-induced thrombocytopenia (DIT) is a condition characterized by low platelet count after administration of a variety of drugs. It is most commonly seen in patients treated with heparin. Its diagnosis is complicated when more than one DIT-causing drug is co-administered. Patients with thrombocytopenia may present with minor or major hemorrhages, depending on the severity of the recess of the platelets.

Case Description: We herein report an uncommon presentation of acute IIb/IIIa glycoprotein inhibitor-induced thrombocytopenia in a 50-year-old male who suffered from myocardial infarction. Serial complete blood counts revealed low platelet counts, rising after discontinuation of the administered IIb/IIIa inhibitor. Recovery was prompt, complete, and sustained with minimal costs.

Conclusion: This report highlights the importance of prompt recognition of severe thrombocytopenia caused by IIb/IIIa inhibitors, particularly tirofiban, by measuring platelet count before and after the initiation of tirofiban, as it can be resolved by the interruption of its infusion and early supportive treatment.

[1]
Rahman N, Jafary FH. Vanishing platelets: Rapid and extreme tirofiban-induced thrombocytopenia after percutaneous coronary intervention for acute myocardial infarction. Tex Heart Inst J  2010; 37(1): 109-12.
 [PMID: 20200641]

[2]
Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J  2016; 37(3): 267-315.
 [http://dx.doi.org/10.1093/eurheartj/ehv320] [PMID: 26320110]

[3]
Yurtdaş M, Yaylali YT, Aladağ N, Özdemir M, Atay MH. Acute serious thrombocytopenia associated with intracoronary tirofiban use for primary angioplasty. Case Rep Med  2014; 2014: 1-3.
 [http://dx.doi.org/10.1155/2014/190149] [PMID: 24715904]

[4]
Mitta A, Curtis BR, Reese JA, George JN. Drug-induced thrombocytopenia: 2019 Update of clinical and laboratory data. Am J Hematol  2019; 94(3): E76-8.
 [PMID: 30549322]

[5]
Gauer RL, Braun MM. Thrombocytopenia. Am Fam Physician  2012; 85(6): 612-22.
 [PMID: 22534274]

[6]
Poullis M, Malik I. Thrombocytopenia and glycoprotein IIb/IIIa inhibitors: causation or association? Circulation  2000; 101(25): E241.
 [http://dx.doi.org/10.1161/01.CIR.101.25.e241] [PMID: 10869280]

[7]
Wessler JD, Giugliano RP. Risk of thrombocytopenia with glycoprotein IIb/IIIa inhibitors across drugs and patient populations: a meta-analysis of 29 large placebo-controlled randomized trials. Eur Heart J Cardiovasc Pharmacother  2015; 1(2): 97-106.
 [http://dx.doi.org/10.1093/ehjcvp/pvu008] [PMID: 27533978]

[8]
Said SM, Hahn J, Schleyer E, et al. Glycoprotein IIb/IIIa inhibitor-induced thrombocytopenia. Clin Res Cardiol  2007; 96(2): 61-9.
 [http://dx.doi.org/10.1007/s00392-006-0459-7] [PMID: 17146606]

[9]
Curtis BR, Divgi A, Garritty M, Aster RH. Delayed thrombocytopenia after treatment with abciximab: a distinct clinical entity associated with the immune response to the drug. J Thromb Haemost  2004; 2(6): 985-92.
 [http://dx.doi.org/10.1111/j.1538-7836.2004.00744.x] [PMID: 15140135]

[10]
Visentin GP, Liu CY. Drug-induced thrombocytopenia. Hematol Oncol Clin North Am  2007; 21(4): 685-696, vi.
 [http://dx.doi.org/10.1016/j.hoc.2007.06.005] [PMID: 17666285]

[11]
Topol EJ, Moliterno DJ, Herrmann HC, et al. Do Tirofiban and ReoPro Give Similar Efficacy Trial. Comparison of two platelet glycoprotein IIb/IIIa inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. N Engl J Med  2001; 344(25): 1888-94.

[12]
Merlini PA, Rossi M, Menozzi A, et al. Thrombocytopenia caused by abciximab or tirofiban and its association with clinical outcome in patients undergoing coronary stenting. Circulation  2004; 109(18): 2203-6.
 [http://dx.doi.org/10.1161/01.CIR.0000127867.41621.85] [PMID: 15117843]

[13]
Christen JR, Soubrier C, Martinez E, et al. Long-lasting thrombocytopenia induced by glycoprotein IIb/IIIa inhibitor. Rev Med Interne  2017; 38(11): 769-73.
 [http://dx.doi.org/10.1016/j.revmed.2017.05.013] [PMID: 28690092]

[14]
Kuter DJ. The biology of thrombopoietin and thrombopoietin receptor agonists. Int J Hematol  2013; 98(1): 10-23.
 [http://dx.doi.org/10.1007/s12185-013-1382-0] [PMID: 23821332]

[15]
Aster RH. Immune thrombocytopenia caused by glycoprotein IIb/IIIa inhibitors. Chest  2005; 127(2) (Suppl.): 53S-9S.
 [http://dx.doi.org/10.1378/chest.127.2_suppl.53S] [PMID: 15706031]

[16]
Sahu KK, Jindal V, Anderson J, Siddiqui AD, Jaiyesimi IA. Current perspectives on diagnostic assays and Anti-PF4 antibodies for the diagnosis of heparin-induced thrombocytopenia. J Blood Med  2020; 11: 267-77.
 [http://dx.doi.org/10.2147/JBM.S232648] [PMID: 32884385]

[17]
Alexander KP, Peterson ED. Minimizing the risks of anticoagulants and platelet inhibitors. Circulation  2010; 121(17): 1960-70.
 [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.853135] [PMID: 20439812]

[18]
Velibey Y, Golcuk Y, Ekmekci A, Altay S, Gunay E, Eren M. Tirofiban-induced acute profound thrombocytopenia: What is the optimal approach to treatment? Platelets  2015; 26(2): 197-8.
 [http://dx.doi.org/10.3109/09537104.2013.787406] [PMID: 23786335]

[19]
Bakchoul T, Marini I. Drug-associated thrombocytopenia. Hematology (Am Soc Hematol Educ Program)  2018; 2018(1): 576-83.
 [http://dx.doi.org/10.1182/asheducation-2018.1.576] [PMID: 30504360]

[20]
Teke HÜ, Teke D. Profound thrombocytopenia related with tirofiban: Will it be enough to only stop medicine? Platelets  2013; 24(4): 335-7.
 [http://dx.doi.org/10.3109/09537104.2012.696749] [PMID: 22720791]

[21]
Said SM, Hahn J, Schleyer E, Müller M, Fiedler GM, Buerke M. Glycoprotein IIb/IIIa inhibitor-induced thrombocytopenia: diagnosis and treatment. Clin Res Cardiol  2007; 96(2): 61-9.