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Acute coronary syndromes
Published in Henry J. Woodford, Essential Geriatrics, 2022
Primary PCI may be offered to people having an NSTEMI, for example, if any of cardiogenic shock, ongoing chest pain despite medical treatment, life-threatening arrhythmias, acute heart failure or dynamic ECG changes are present.2,12 Angiography, with or without PCI, may be performed in high-risk people within 24 hours following initial medical treatment for NSTEMI. Unless there is a plan for early intervention, fondaparinux (2.5 mg subcutaneously daily) is recommended. Alternative anticoagulation strategies are adopted for people having early PCI.2 Antiplatelet drugs are also prescribed seeFigure 20.1. Nitrates (including sublingual) and beta-blockers (when no contraindications) are recommended for control of persisting symptoms.2
Thromboembolic disease
Published in Catherine Nelson-Piercy, Handbook of Obstetric Medicine, 2020
Some women (1%–2%) develop a local allergic reaction to LMWH. If this occurs, women usually develop a similar localized pruritic urticarial skin eruption to all forms of UFH and LMWH. In these unusual cases, heparinoids such as danaparoid or fondaparinux (see next) have been used successfully and seem safe during pregnancy and breastfeeding.
Anti-coagulation in acute coronary syndrome
Published in K Sarat Chandra, AJ Swamy, Acute Coronary Syndromes, 2020
Nitin Parashar, Deepti Siddharthan, Sivasubramanian Ramakrishnan
Fondaparinux is a synthetic analogue of antithrombin-binding sequence. It requires the presence of antithrombin for its action and causes inhibition of factor Xa only without affecting factor IIa. The drug is administered once daily by subcutaneous route. Because of its renal clearance, it should be given cautiously to patients with renal dysfunction and should be avoided when creatinine clearance is less than 20 mL/min.
Belgian clinical guidance on anticoagulation management in hospitalised and ambulatory patients with COVID-19
Published in Acta Clinica Belgica, 2022
Thomas Vanassche, Christelle Orlando, Kristel Vandenbosch, Alain Gadisseur, Cédric Hermans, Kristin Jochmans, Jean-Marc Minon, Serge Motte, Harlinde Peperstraete, Pierre Péters, Muriel Sprynger, Patrizio Lancellotti, Isabelle Dehaene, Patrick Emonts, Christophe Vandenbriele, Peter Verhamme, Cécile Oury
Low molecular weight heparin (LMWH) is the recommended therapy for pharmacological thromboprophylaxis in critically ill patients, with the exception of patients with severe renal dysfunction (for whom unfractionated heparin could be considered based on a careful risk/benefit assessment) and patients with a history of heparin-induced thrombocytopenia [24,25]. In the latter, fondaparinux is an alternative drug for the prevention or treatment of thrombosis, although it is not reimbursed for hospitalised patients in Belgium. Several experimental antivirals used to treat COVID-19 may increase plasma levels of direct oral anticoagulant (DOAC) because of P-glycoprotein inhibition and/or competition, inhibition or induction of CYP3A4-dependent pathways [26]. Therefore, parenteral LMWH is the preferred agent for thromboprophylaxis [26]. Although interim guidelines agree on the choice of thromboprophylaxis, the optimal anticoagulant dose in COVID-19 in patients is unknown; intermediate- or full-dose regimens rather than prophylactic doses have been suggested but higher doses also cause more bleeding [3,27].
Heparin-induced thrombocytopenia: pathophysiology, diagnosis and treatment
Published in Expert Review of Hematology, 2021
Anne-Mette Hvas, Emmanuel J Favaloro, Maja Hellfritzsch
Fondaparinux is a synthetic pentasaccharide also possessing an antithrombin-dependent inhibition of factor Xa. Fondaparinux is approved for prophylaxis and treatment of venous thromboembolism. Although it has not been approved for treatment in HIT, it has been used off-label for this indication for the past 20 years. Only observational evidence exists for the use of fondaparinux in the context of HIT. The evidence was summarized in a systematic review by Linkins et al., including nine observational studies, of which seven studies were retrospective, including in total 154 patients with laboratory confirmed HIT [57]. Overall, rates of thrombosis, bleeding and death supported fondaparinux as an effective and safe treatment option in HIT patients [57]. The major shortcomings of fondaparinux is a long half-life and renal elimination leading to a contraindication in patients with creatinine clearance below 30 mL/min, which is challenging in critically ill patients. Besides, potential cross-reactivity with HIT-antibodies also exists [58].
Fondaparinux cross-reactivity in heparin-induced thrombocytopenia successfully treated with high-dose intravenous immunoglobulin and rivaroxaban
Published in Platelets, 2020
Farheen Manji, Theodore E. Warkentin, Jo-Ann I. Sheppard, Adrienne Lee
Fondaparinux cross-reactivity as an explanation for treatment failure with this anticoagulant appears to be rare. Indeed, a low frequency of fondaparinux cross-reactivity (vis-à-vis UFH and low-molecular-weight heparin) was proven in a clinical trial[22], and is regarded as a major advantage of this pentasaccharide anticoagulant[23,24]. Linkins and colleagues [14] performed a systematic review of studies describing fondaparinux for the treatment of HIT. These authors identified no cases of putative fondaparinux cross-reactivity among the 154 patients reported in the 9 studies reviewed; based on these results, they concluded that the upper 95% confidence limit for this adverse effect would be approximately 3%. Nevertheless, our case and the supportive laboratory studies indicate that clinically relevant fondaparinux cross-reactivity does exist, albeit rare.