Background A female with renal failure (renal clearance <20 ml/min), uncontrolled blood clotting, allergic to LMWH, suffered bruising, epistaxis and gastrointestinal bleeding with haemodynamic compromise, requiring repeated transfusions, when she was treated with acenocoumarol.
Purpose To design a therapeutic strategy to control the clotting in this patient.
To describe the most efficient method of preparing argatroban vials.
Material and methods Other alternatives were evaluated (lepirudin, fondaparinux and new oral anticoagulants, NOACs).
A literature review was made to determine drug stability in syringes and polypropylene bags, at different concentrations and storage conditions, to develop a solution with the optimal concentration that allowed us the most efficient use of the vial.
Results NOACs and fondaparinux are contraindicated in renal failure, and lepirudin has not been marketed since 2012.
The possible alternatives were danaparoid and argatroban, the latter being the more cost-effective.
Argatroban solutions are stable for 14 days under natural light and temperatures between 2°C and 8°C, in 0.9% NaCl or glucose solution, at 1 mg/ml, when packed in polypropylene syringes and bags. Moreover, they are stable under natural light and 25°C, in 0.9% NaCl at 0.2 mg/ml in the same type of packaging for 180 days. Doses of the initial bolus (13 mg) and the doses administered as a continuous infusion during dialysis (18 mg administered at 6 mg/hour), were in accordance with the Product Information.
Considering the stability conditions and the doses required by the patient, half the vial (1.25 ml) was prepared in a bag with a total volume of 125 ml, at a concentration of 1 mg/ml, from which was obtained the initial bolus and the continuous infusion for 4 dialysis sessions (taking place over 14 days).
Conclusion We succeeded in controlling clotting in this patient. The method of preparation allowed us to make the most efficient use of the argatroban vial.
Coventry DA. Webster NR: Heparin-induced thrombocytopenia and the health economic analysis of argatroban. BJA 2014;112:964–7
ReferenceNo conflict of interest.