Anti-platelet agent reversal
- Consider reversal of aspirin and clopidogrel in acute life threatening hemorrhage, but it is very controversial in ICH
- PATCH trial in 2016 suggested mortality is higher in platelet transfused patients, alongside several other preceding studies
- 2.05 OR, increased odds of death at 3 months in platelet transfusion group
- 190 ICH patients enrolled
- Included patients with at least 7 days of antiplatelet therapy, including ASA, clopidogrel, dipyridamole
- Excluded SDH, epidural hemorrhage, aneurysm, AVM, surgical evacuation of ICH within 24 hrs, thrombocytopenia < 100k, use of warfarin if INR > 2-3, infratentorial hematomas, large intraventricular hemorrhage
- Anti-platelet medications to reverse:
- Prevalence of immediate traumatic ICH in pts on clopidogrel 12% compared to 5% on warfarin
- May be confounded by pts on warfarin having low threshold for presenting with head injury to ED, but highlights high frequency of bleeds in pts on clopidogrel
- However, no pts on clopidogrel had delayed ICH compared to ~1% pts on warfarin with delayed ICH
- Delayed ICH defined as traumatic ICH within 2 wks after initial normal CTH
- Platelet aggregation recovery:
- 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
- If 350mg loading dose, platelet inhibition occurs within 2-5 hrs
- 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
- Platelet transfusion volume:
- Desmopressin (DDAVP)
- Chronic renal failure patients may benefit from:
- Ticagrelor does not likely respond to platelet transfusion reversal
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- Baharoglu MI et al. Platelet Transfusion Versus Standard Care After Acute Stroke due to Spontaneous Cerebral Haemorrhage Associated with Antiplatelt Therapy (PATCH): A Randomised, Open-Label, Phase 3 Trial. Lancet 2016; 1 – 9.
- Nishijima DK et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012 Jun;59(6):460-8.e1-7.
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- 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.
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- 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.