Anti-platelet agent reversal
Background
- Consider reversal of aspirin and clopidogrel in acute life threatening hemorrhage, primarily ICH[1]
- Anti-platelet medications to reverse:
- Aspirin
- Clopidogrel
- Ticagrelor
- Ticlopidine (rarely used anymore)
- Platelet aggregation recovery[4]:
- Within 4 days of stopping aspirin
- Takes 10 days for clopidogrel (life-span of a platelet)
- When starting clopidogrel, takes 7 days to achieve max platelet inhibition[5]
- If 350 mg loading dose, plt inhibition occurs within 2-5 hrs
Reversal
- If time permits, obtain initial platelet function assay for aspirin and clopidogrel
- Reversal with combination of platelet transfusion, desmopressin
- Limited evidence to support mortality improvement in reversal, but little evidence of harm[6]
- Platelet transfusion volume:
- Desmopressin (DDAVP)[9]
- 0.3 mcg/kg/dose in 50 cc NS over 30 min[10]
- Quick onset of action, within 1 hr
- Similar MOA to cryoprecipitate (increase factor VIII, vWF)
- No transfusion complications of cryoprecipitate
- However, effects only last up to 24 hrs, and tachyphylaxis limits efficacy repeated doses
Special Circumstances
- Chronic renal failure pts may benefit from:
- Desmopressin
- OR cryoprecipitate 1 unit
- Conjugated estrogens IV 0.6 mg/kg/d for 5 days[11]
- See uremic bleeding
- Ticagrelor does not likely respond to platelet transfusion reversal[12][13]
Sources
- ↑ Ohm C, Mina A, Howells G, et.al. Effects of antiplatelet agents on outcomes for elderly patients with traumatic intracranial hemorrhage. J Trauma. 2005;58:518-22.
- ↑ Wong DK, Lurie F, Wong LL. The effects of clopidogrel on elderly traumatic brain injured patients. J Trauma. 2008;65:1303-8.
- ↑ Saloheimo P, Ahonen M, Juvela S, et.al. Regular aspirin-use preceeding the onset of primary intracerebral hermoorhage is an independent predictor for death. Stroke. 2006;37:129-33.
- ↑ Li C et al. Reversal of the anti-platelet effects of aspirin and clopidogrel. J Thromb Haemost. 2012 Apr;10(4):521-8.
- ↑ Vilahur G, Choi GB, Zafar MU et.al. Normalization of platelet reactivity in clopidogrel-treated subjects. J Thromb Haemost. 1997;5:82-90.
- ↑ Orlando Regional Medical Center. Department of Surgical Education. ANTIPLATLET AGENT REVERSAL IN ADULTS WITH TRAUMATIC INTRACRANIAL HEMORRHAGE. http://www.surgicalcriticalcare.net/Guidelines/TBI%20Antiplt%20Reversal%20Guideline%202012.pdf.
- ↑ Powner DJ, Hartwell EA, Hoots WK, et.al. Counteracting the effects of anticoagulants oand antiplatelet agents during neurosurgical emergencies. Neurosurgery. 2005; 57:823-31.
- ↑ Downey DM, Monsn B, Butler KL, et.al. Does platelet administration affect mortality in elderly headinjured patients taking antiplatelet medications? Am Surg. 2009;75(11):1100-3.
- ↑ Hedges SJ, Dehoney SB, Hooper JS, et.al. Evidence-based treatment recommendations for uremic bleeding. Nature Clin Prac. 2007;3(3):138-53.
- ↑ . Gratz I, Koehler J, Olsen D, et.al. The effect of desmopressin acetate on postoperative hemorrhage in patients receiving aspirin therapy before coronary artery bypass operations. J Thorac Cardiovasc Surg. 1992; 104:1417-22.
- ↑ Livio M, Mannucci PM, Viganò G, et.al. Conjugated estrogens for the management of bleeding associated with renal failure. N Engl J Med. 1986; 315:731-5.
- ↑ Martin AC et al. The effectiveness of platelet supplementation for the reversal of ticagrelor-induced inhibition of platelet aggregation: An in-vitro study. Eur J Anaesthesiol. 2016 May;33(5):361-7.
- ↑ Godier A et al. Inefficacy of Platelet Transfusion to Reverse Ticagrelor. N Engl J Med 2015; 372:196-197.