Management of argatroban surrounding a lumbar puncture: A case report
Authors: Andrew C. Faust, Carrie S. Oliphant
Journal: American Journal of Hematology (2011)

To prevent thrombotic complications of heparin-induced thrombocytopenia (HIT), full anticoagulation with an alternative anticoagulant is required. As there are no antidotes or reversal agents for direct thrombin inhibitors (DTIs), there is substantial risk in managing anticoagulation in the setting of neuraxial procedures and little information on the management of DTIs [1-5]. A 77-year-old woman was admitted to the neurology service after presenting to the emergency department with seizures. On day 6 of hospitalization, prophylactic unfractionated heparin was started. Her platelets were 330,000 μL−1 on initiation of heparin and dropped to 104,000 μL−1 by day 3. Although the platelet drop was rapid, she had 8 days of heparin exposure during a recent hospitalization. Therefore, heparin was discontinued and a platelet factor-4 antibody was drawn [which returned positive (optical density 2.30; normal <0.45)]. An argatroban infusion was started at 1 μg kg−1 min−1 with an activated partial thromboplastin time (aPTT) goal of 45–90 sec. On day 2 of argatroban therapy, the patient seized again and her neurologist wished to perform a lumbar puncture. The patient's aPTT was now 77.5 sec on 4.4 mg hr−1 of argatroban. It was recommended to hold the argatroban for 2 hr and check an aPTT immediately before the procedure. This aPTT returned within normal limits (34 sec) and the neurologist proceeded with the lumbar puncture. The procedure was uncomplicated, with the cerebrospinal fluid collected revealing clear, colorless fluid and no red or white blood cells. Two hours after the procedure, the argatroban infusion was restarted and a therapeutic aPTT (65.8 sec) was achieved ∼18 hr later. We observed no complications of this management strategy. To our knowledge, this is the first reported case of a spinal procedure being successfully performed in a nonobstetric patient requiring argatroban therapy for HIT. A MEDLINE search was conducted, using the terms “argatroban,” “hirudins,” “direct thrombin inhibitors,” “spinal procedures,” “hematoma, epidural, spinal,” and “injections, epidural,” which returned only four articles in the English language. Three of these four articles focused on DTI use in obstetrics. Several review articles have been published regarding the management of anticoagulants and antiplatelet agents surrounding neuraxial procedures, with most recommending stopping argatroban 4 hr before a procedure and resuming 2–4 hr postprocedure [1-5]. In our case, we held the drug for 2 hr before the lumbar puncture, resulting in the normalization of the aPTT. Similar to our management strategy, Ekbatani et al. [4] described the successful management of argatroban in an actively laboring HIT patient. These authors held the argatroban for 2 hr, with resultant normalization of the aPTT and epidural analgesia was started after another 2 hr. The patient's epidural catheter was removed 2 hr after delivery, anticoagulation was resumed 2 hr after removal, and no complications were observed after 1 month. Our recommendation was also based on the half-life of the drug (30–51 min) [6]. Because of extensive hepatic metabolism, the duration of discontinuing the argatroban before the lumbar puncture would need to be lengthened in the presence of liver dysfunction. Andrew C. Faust*, Carrie S. Oliphant , * Department of Pharmacy, Methodist University Hospital 1265 Union Avenue, Memphis, Tennessee 38104, Department of Pharmacy, Methodist University Hospital 1265 Union Avenue, Memphis Tennessee 38104.