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

Authors

Chinonso Onuoha, Department of Pediatrics, East Carolina University, Vidant Medical Center, Greenville, North Carolina, USA
Karen D. Barton, Medical Center Library, Duke University Medical Center, Durham, North Carolina, USA
Edward C C Wong, Department of Pediatrics and Pathology, George Washington School of Medicine and Health Sciences, Washington, DC, USADepartment of Coagulation, Quest Diagnostics, Nichols Institute, Centreville, Virginia, USA
Jay S. Raval, Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
Marian A. Rollins-Raval, Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
Tina A. Ipe, Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
Joseph E. Kiss, Department of Medicine, Vitalant Northeast Division and The University of Pittsburgh, Pittsburgh, Pennsylvania, USA
Leonard I. Boral, Department of Pathology and Laboratory Medicine, University of Kentucky Health Care, Lexington, Kentucky, USA
Jill Adamksi, Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Phoenix, Arizona, USA
Nicole D. Zantek, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
Oluwatoyosi A. Onwuemene, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA

Document Type

Article

Publication Date

11-1-2020

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 equally used as initial therapy. Heparin re-exposure occurred without thrombotic event in 29 TPE-treated patients and three IVIG-treated patients.

CONCLUSION: In patients with HIT, both TPE and IVIG are used for initial therapy or treatment of refractory HIT. However, TPE is more commonly used in patients undergoing CPB. Prospective studies may help clarify which treatment is indicated in HIT population subsets.

Recommended Citation

Onuoha C, Barton KD, Wong ECC, Raval JS, Rollins-Raval MA, Ipe TS, Kiss JE, Boral LI, Adamksi J, Zantek ND, Onwuemene OA. Therapeutic plasma exchange and intravenous immune globulin in the treatment of heparin-induced thrombocytopenia: A systematic review. Transfusion. 2020 Nov;60(11):2714-2736. doi: 10.1111/trf.16018. Epub 2020 Aug 19. PMID: 32812222.