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ANTICOAGULATION

Compliance with Platelet Count Monitoring Recommendations and Management of Possible Heparin-Induced Thrombocytopenia in Hospitalized Patients Receiving Low-Molecular-Weight Heparin

Candidate, Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University; Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands

Patricia MLA van den Bemt, PhD

Hospital Pharmacist, Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University; Department of Hospital Pharmacy, Erasmus Medical Center, Rotterdam, Netherlands

Albert Huisman, PhD

Clinical Chemist, Department of Clinical Chemistry and Haematology, University Medical Center Utrecht

Alfred FAM Schobben, PhD

Hospital Pharmacist and Professor of Clinical Pharmacotherapy, Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University; Department of Clinical Pharmacy, University Medical Center Utrecht

Toine CG Egberts, PharmD PhD

Hospital Pharmacist and Professor of Clinical Pharmacy, Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University; Department of Clinical Pharmacy, University Medical Center Utrecht

Wouter W van Solinge, PhD

Clinical Chemist and Professor of Clinical Chemistry and Laboratory Medicine, Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University; Department of Clinical Chemistry and Haematology, University Medical Center Utrecht

Reprints: Prof. Dr. van Solinge, Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, PO Box 80082, 3508 TB Utrecht, Netherlands, fax 31(0)30 2539166, wsolinge{at}umcutrecht.nl

BACKGROUND: Summaries of product characteristics (SPCs) and clinical guideline recommendations are available for monitoring the platelet count for heparin-induced thrombocytopenia (HIT) in patients receiving low-molecular-weight heparin (LMWH). Testing for the presence of heparin-platelet factor 4 antibodies (HPF4-Ab) and starting alternative anticoagulation is recommended when HIT is suspected.

OBJECTIVE: To investigate the frequency of compliance with recommendations for platelet count monitoring and management of possible HIT in hospitalized patients receiving prophylaxis and treatment dosing of LMWH for at least 5 consecutive days.

METHODS: A retrospective cohort study within the Utrecht Patient Oriented Database (UPOD) was conducted. For all inpatients, all episodes of exposure to dalteparin or nadroparin for at least 5 consecutive days in 2004-2005 were selected. In 4 different nonexclusive groups of patients (all pts. receiving dalteparin, all pts. receiving nadroparin, surgical pts. with a prophylactic dose of either dalteparin or nadroparin, and pts. exposed to unfractionated heparin [UFH] within 100 days before receiving either dalteparin or nadroparin), compliance with recommendations for platelet count monitoring from SPCs and a clinical guideline was studied. The frequency of compliance with these recommendations was determined. In addition, it was determined whether patient and treatment characteristics were associated with regular platelet count monitoring. Finally, the frequency of testing for HPF4-Ab and the initiation of danaparoid treatment in patients with a drop of at least 50% in platelet count were investigated.

RESULTS: A total of 6804 patients, with 7770 episodes of LMWH treatment, were included in the analysis. The frequency of compliance with platelet count monitoring recommendations was 26.3% for all patients receiving dalteparin, 35.6% for all patients receiving nadroparin, 23.0% for surgical patients receiving prophylactic dosing of either dalteparin or nadroparin, and 41.5% for patients exposed to UFH within 100 days before the start of either dalteparin or nadroparin treatment. Regular platelet count monitoring was strongly positively associated with medical patients (relative risk [RR] 2.33), surgical patients (RR 2.03), critically ill patients (RR 2.80), and those with recent exposure to UFH (RR 2.19). The frequency of testing for HPF4-Ab was 5.4% and the initiation of alternative anticoagulation with danaparoid in patients with a 50% drop in platelet count was 0%.

CONCLUSIONS: The results suggest that compliance with recommendations for platelet count monitoring and management of possible HIT is low at our institution. Policies and tools to improve compliance with recommended laboratory monitoring should be developed to secure the safe use of LMWH and other medications.

Key Words: compliance, heparin-induced thrombocytopenia, low-molecular-weight heparin, monitoring, patient safety

Published Online, August 18, 2009. www.theannals.com, DOI 10.1345/aph.1L646

Related articles in The Annals:

A Benchmark for Platelet Count Monitoring with Low-Molecular-Weight Heparin: Expanding Implementation of National Patient Safety Goals

Sarah A Spinler
The Annals 2009 43: 1519-1521. [Abstract] [Full Text]  

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				S. A Spinler A Benchmark for Platelet Count Monitoring with Low-Molecular-Weight Heparin: Expanding Implementation of National Patient Safety Goals Ann. Pharmacother., September 1, 2009; 43(9): 1519 - 1521. [Abstract] [Full Text] [PDF]