Intravenous immunoglobulin (IVIG) helped resolve the effects of vaccine-induced thrombotic thrombocytopenia (VITT) in 3 patients after receiving the AstraZeneca COVID-19 vaccine.
After high doses of IVIG, all three patients with VITT experienced decreased platelet activation due to antibodies, reported Dr. Ishac Nazy of McMaster University in Hamilton, Ontario.
All patients had arterial thrombosis and two also had venous thrombosis. However, none of the patients showed signs of new or progressive thrombosis after IVIG treatment. New England Journal of Medicine..
The authors noted that VITT mimics autoimmune heparin-induced thrombocytopenia and that large amounts of IVIG reduce platelet activation. They added that immunoglobulins used “similarity” to autoimmune heparin-induced thrombosis, which “rapidly increases platelet counts and reduces hypercoagulation,” due to the lack of data on the treatment of patients with VITT. It was.
Three patients are in Canada and the AstraZeneca vaccine is recommended for adults 55 years and older. Two men aged 63 and 69 and a woman aged 72 showed symptoms of VITT 1 week to 18 days after vaccination.
Female patients and 63-year-old male patients had no significant medical history and no cardiovascular risk factors. The first symptom was the onset of foot pain. During the presentation, images of both patients showed evidence of arterial thrombosis. VITT was unsuspected in either patient and both were treated with heparin or tinzaparin (low molecular weight heparin) and underwent surgical embolectomy.
When VITT was suspected, dosing was switched to argatroban or fondaparinux, and both patients received high doses of IVIG. The female patient’s platelet count increased and she was returned home. However, the male patient did not report new thrombosis, but he was awaiting amputation because previous thrombosis caused ischemic necrosis of the distal foot.
A 69-year-old male patient was recently diagnosed with insulin-dependent diabetes mellitus, obstructive sleep apnea, and recently prostate cancer, but had no history of thrombosis. He was exposed to heparin during transcatheter valve replacement 9 months ago and started daily aspirin therapy. The patient came to the hospital with headache and confusion and progressive left weakness. He had a right middle cerebral artery attack. Imaging revealed an arterial thrombus and he was treated with fondaparinux and IVIG. No new blood clots developed.
He did not recover from thrombocytopenia, so he was given additional IVIG and switched to rivaroxaban (Xarelto). After therapeutic plasmapheresis, he experienced a gradual improvement in platelet count.
After IVIG treatment, platelet counts increased in all three patients. Two of the three patients had findings “consistent with reduced hypercoagulability,” that is, decreased D-dimer levels and continuous improvement in fibrinogen levels.
All patients tested positive for platelet factor 4 (PF4) antibody. However, the authors said that after administration of IVIG, all three patients showed at least some decrease in reactivity in the presence of PF4.
“Patients with VITT can suffer from severe thrombocytopenia, which can last for weeks, so early administration of IVIG may be an important adjunct to anticoagulant therapy for the management of VITT. There is, “they say.
They also recommended a serotonin release assay to help diagnose VITT, but Nazy’s group warned that “VITT antibodies” should be tested “to avoid false results in the serotonin release assay” before IVIG administration. ..
The CDC recommends avoiding heparin administration to patients with thrombosis with thrombocytopenia syndrome (TTS) after Johnson & Johnson vaccination.In the presentation 21 TTS cases dating back to AprilThe agency noted that eight patients were treated with immunoglobulins.
This study was supported by the Canadian Institute of Health.
Bourguignon has not revealed a conflict of interest.
Nazy did not reveal a conflict of interest.
One co-author revealed various connections with the industry.
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