Lepirudin and Vitamin K Antagonists

Long-term treatment of HIT patients often involves a transition from DTI to oral anticoagulation. Initiation of the transition to vitamin K antagonist (coumarin) therapy should begin only after the platelet count has substantially recovered (preferably, >150 x 109/L), with a minimum of 5 days of overlapping therapy with an alternative anticoagulant, and with the last 2 days stably within the target therapeutic range (Warkentin and Greinacher, 2004). In patients with deep vein thrombosis (DVT) associated with acute HIT, the use of vitamin K antagonist can be associated with venous limb gangrene, which typically occurs when this anticoagulant is used alone for treatment of HIT, or when overlapping therapy with DTIs is not managed appropriately, e.g., early initiation of coumarin and premature discontinuation of the DTI.

TABLE 2 Initial Lepirudin Dosing in Renal Dysfunction


Initial iv infusion rate

creatinine mg/dL

(subsequently adjusted to aPTT)



1-1.58 (90-140)

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