Argatroban is a hepatically metabolized,
direct thrombin inhibitor used for prophylaxis or treatment of
thrombosis in
heparin-induced
thrombocytopenia (HIT) and for patients with or at risk of HIT undergoing
percutaneous coronary intervention (PCI). The objective of this review is to summarize practical considerations of
argatroban therapy in HIT. The US FDA-recommended
argatroban dose in HIT is 2 microg/kg/min (reduced in patients with hepatic impairment and in paediatric patients), adjusted to achieve activated partial
thromboplastin times (aPTTs) 1.5-3 times baseline (not >100 seconds). Contemporary experiences indicate that reduced doses are also needed in patients with conditions associated with hepatic hypoperfusion, e.g.
heart failure, yet are unnecessary for renal dysfunction, adult age, sex, race/ethnicity or
obesity.
Argatroban 0.5-1.2 microg/kg/min typically supports therapeutic aPTTs. The FDA-recommended dose during PCI is 25 microg/kg/min (350 microg/kg initial bolus), adjusted to achieve activated clotting times (ACTs) of 300-450 sec. For PCI,
argatroban has not been investigated in hepatically impaired patients; dose adjustment is unnecessary for adult age, sex, race/ethnicity or
obesity, and lesser doses may be adequate with concurrent
glycoprotein IIb/IIIa inhibition.
Argatroban prolongs the International Normalized Ratio, and published approaches for monitoring the
argatroban-to-
warfarin transition should be followed. Major
bleeding with
argatroban is 0-10% in the non-interventional setting and 0-5.8% periprocedurally.
Argatroban has no specific
antidote, and if excessive anticoagulation occurs,
argatroban infusion should be stopped or reduced. Improved familiarity of healthcare professionals with
argatroban therapy in HIT, including in special populations and during PCI, may facilitate reduction of harm associated with HIT (e.g. fewer
thromboses) or its treatment (e.g. fewer
argatroban medication errors).