替罗非班致重度血小板减少症的诊疗策略及病例分析

Diagnosis and treatment recommendations and case study of severe thrombocytopenia caused by tirofiban

目的探讨替罗非班致重度血小板减少症的临床表现、诊断、鉴别诊断及治疗策略。方法收集2021年12月至2023年3月在本院住院期间使用替罗非班导致极重度血小板减少症的7名急性冠脉综合征患者的基本临床资料、血小板计数变化及治疗经过,分析其个性及共性特征。结果7例患者入院时血小板计数均在正常范围,其中6名患者血小板减少发生时间在使用替罗非班后3~16 h,1名患者是在使用替罗非班后34 h检测时被发现,血小板计数最低值范围为(1~11)×10^(9)/L。7名患者均停用了替罗非班及其他抗栓药物,其中6名患者停药后2~4 d,血小板计数升高到50×10^(9)以上,后续血小板计数均逐渐恢复至正常范围内,期间均未发生出血和急性血栓事件,也未进行血小板输注;5名患者待血小板计数恢复到(20~50)×10^(9)/L时恢复抗栓治疗,1名患者待计数提升到50×10^(9)/L以上时进行了择期冠状动脉旁路移植术(CABG),1名患者血小板减少后有出血症状,且需要限期CABG手术,连续输注了血小板3 U,同时进行免疫球蛋白治疗,血小板计数升高到76×10^(9)/L时进行了CABG手术。对此7例患者血小板减少原因均进行了鉴别诊断,排除了肝素等其他原因所致的血小板减少。归纳并总结了此类药物致重度血小板减少症的诊疗流程图。结论替罗非班可引起急性重度或极重度血小板减少,用药后6 h常规检测血小板,出现血小板减少后及时停用替罗非班可避免严重不良事件发生。同时根据患者有无出血及出血风险决定是否进行血小板输注,根据血小板计数恢复情况及血栓风险决定恢复抗栓治疗时机。

Objective To investigate the clinical manifestations,diagnosis,differential diagnosis and management strategies of thrombocytopenia caused by tirofiban.Methods The basic clinical data,platelet count changes and treatment course of 7 patients with acute coronary syndrome who used tirofiban resulting in severe thrombocytopenia during their hospitalization in our hospital from December 2021 to March 2023 were collected,and their individual and common characteristics were analyzed.Results Platelet counts were in the normal range in all 7 patients on admission.Six of the patients had thrombocytopenia occurring from 3 to 16 hours after tirofiban use,and one patient was detected at 34 h of tirofiban use.Their minimum platelet count ranged from(1-11)×10^(9)/L.All 7 cases discontinued tirofiban and other antithrombotic drugs,and the platelet count increased to 50×10^(9)/L in 6 patients in 2 to 4 days after stopping the drug and gradually returned to the normal range.During this period,there were no bleeding or acute thrombotic events,and no platelet transfusion was conducted.Five patients resumed antithrombotic therapy when the platelet count returned to(20-50)×10^(9)/L,1 patient underwent elective coronary artery bypass grafting(CABG)surgery when the count rose above 50×10^(9)/L.One patient had bleeding manifestations after thrombocytopenia and required limited-duration CABG surgery,so 3 U platelet transfusion and immunoglobulin treatment were performed consecutively.CABG surgery was performed when the platelet count increased to 76×10^(9)/L.The differential diagnosis of the cause of thrombocytopenia was performed in all seven patients,and other causes of thrombocytopenia,such as heparin,were excluded.Conclusion Tirofiban can cause acute severe or extremely severe thrombocytopenia.Routine platelet count testing at 6 hours after medication can prevent serious adverse events by discontinuing tirofiban promptly after thrombocytopenia occurs.At the same time,it is determined whether to perform platelet transfusion based on whether the patient has bleeding and the risk of bleeding,and the timing of resuming antithrombotic treatment is determined based on the recovery of platelet count and the risk of thrombosis.