Clopidogrel Induced Thrombotic Thrombocytopenic Purpura-Juniper Publishers : JuniperPublishers-CC

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March 23, 2021 0 Comments


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Juniper Publishers-Journal of Cardiology


Clopidogrel is often used drug in cardiology observe. Although apparently benign, it could hardly ever caus! e Thombotic Thrombocytopenic Purpura (TTP). Mechanism of motion by which Clopidogrel causes TTP is totally different than typical. This makes the scenario extra attention-grabbing. Right here we’re presenting a case of NSTEMI who developed TTP after Clopidogrel. Prognosis is solely medical. Early analysis and plasmapheresis is lifesaving. A 66-year-old feminine presents to the hospital for brand new onset of chest ache. After laboratory and diagnostic workup, NSTEMI was identified. Affected person underwent catheterization the place triple vessel illness was discovered, solely amenable to CABG. Throughout therapy of NSTEMI, affected person obtained Clopidogrel for two days, which was subsequently held in preparation for CABG. After CABG, Clopidogrel was restarted and affected person began having dramatic decreases in platelet depend and haemoglobin requiring blood transfusions. Peripheral smear confirmed schistiocytes,polychromasia , nucleated purple blood cells and low platelets. Due to persistent platelet drop, haemolysis and uraemia concern for TTP was raised. As Clopidogrel was just lately began, it was thought of the etiological issue. Clopidogrel was held, and plasma alternate was instantly began with steroid remedy whereas ADAMSTS-13 ranges have been pending. After 7 days of plasma alternate and 5 days of steroids, platelet counts and haemoglobin subseq! uently elevated to acceptable ranges. ADMASTS-13 ranges got here again regular indicating totally different mechanism to induce TTP than what has been extensively studied within the literature.

Key phrases: CKD 5: Power Kidney Illness Stage 5; MAHA: Microangiopathic Hemolytic Anemia; PCI: Percutaneous Coronary Intervention; TTP: Thrombotic Thrombocytopenic Purpuran

Affected person Case

A 66 year-old-female with previous medical historical past of power kidney illness stage 5 (CKD-5) not on hemodialysis, hypertension, diabetes mellitus kind 2 presents to the emergency division with new onset chest ache and shortness of breath for the previous two weeks. Vitals revealed affected person to be saturating 86% on room air, requiring 3L of nasal cannula. All different vitals secure. On bodily examination, affected person had a jugular venous distention. Bilateral course rhonchi have been heard on pulmonary examination. All different bodily examination findings have been regular. Laboratory outcomes revealed hemoglobin of 8.9, which was affected person’s baseline, platelet depend of 266, creatinine of 6.2. Affected person had a troponin elevation and T wave inversion in lateral leads. Resulting from concern for NSTEMI, affected person was given Aspirin 325mg and Clopidogrel 75mg and brought for left coronary heart catheterization the subsequent day.

Affected person, on day of catheterization was given 300mg of Plavix. Catheterization revealed triple vessel illness, amenable to CABG. Plavix was held for 9 days as affected person was awaiting platelet operate to enhance for CABG. In the course of the interim, affected person had worsening renal operate secondary to distinction load throughout catheterization, and hemodialysis was began. Affected person was additionally requiring packed purple blood cell transfusions for hemoglobin of seven. EPO was additionally began due to low iron and TIBC ranges secondary to power illness from CKD. CABG was carried out on day 10 of hospital keep. Affected person tolerated surgical procedure effectively and clopidogrel was restarted after surgical procedure was carried out.

The night of CABG, affected person had a major platelet drop to 89 with no indicators of bleeding. Affected person did begin to have straightforward bruising of extremities. There was additionally concern for a concomitant thrombogenic course of secondary to affected person’s dialysis line forming clots twice inside a 3 day interval. 4T rating was 4. Heparin was held and Heparine Induced Thrombocytopenia work up was despatched. Platelet continued to drop on Argatroban, which made us to think about one other analysis as etiology. A peripheral smear was carried out which confirmed quite a few schistocytes. LDH was 572, Reticulocyte depend was 4.67, Haptoglobin was 46. Due to thrombocytopenia, hemolytic anemia and worsening kidney operate, TTP was a regarding differential analysis, particularly after current administration of clopidogrel.

Clopidogrel was instantly held and affected person was began on plasma alternate remedy as ADAMST-13 was pending. Prednisone 80mg every day was began as effectively. Imply time HIT antibody got here again constructive however Serotonin Launch Assay was destructive. Platelet depend went up subsequently within the subsequent few days with Plasma alternate with after 7 days of plasma alternate remedy and 5 days of prednisone remedy, platelet depend went to 122 and hemoglobin 9.5 with none must extra blood transfusions. Peripheral smear revealed decreased schistocytes and elevated platelets. ADAMTS-13 was discovered to be regular.


TTP is called a thrombotic microngiopathic syndrome, which will be prompted acquired or hereditary etiology. The acquired kind, as seen on this affected person, is brought on by auto antibodies that kind in opposition to the metalloprotease ADAMTS-13 [1], which finally cleaves von-willibrand issue, a big multimer. A lower on this protease exercise permits this massive multimer to bind to platelets and in flip, creating microthrombi, thrombocytopenia and microvascular occlusion [2]. Microangiopathic hemolytic anemia (MAHA) can also be seen within the type of schistocytes as erythrocytes are broken by the big multimer-platelet complexes. TTP classically features a pentad of options: MAHA, thrombocytopenia, fever, renal abnormalities and neurologic disturbance [3]. On this case, the TTP was medicine induced secondary to clopidogrel utilization. In response to the Oklahoma TTP-HUS registry in 2013, within the grownup inhabitants, TTP is seen in 3 circumstances per a million adults, 76% of whom have been females [4].

Clopidogrel is an anti-platelet medicine generally used along side aspirin primarily for sufferers throughout acute coronary syndrome or after percutaneous coronary intervention (PCI) to forestall re-instant thrombosis. The medicine works by irreversibly blocking the P2Y12 part of the ADP receptors on the platelet floor, which finally prevents platelet aggregation [5]. Clopidogrel has extensively changed Ticlodipine, one other structurally comparable antiplatelet medicine, on account of its bigger security profile [6]. Ticlodipine was discovered to have elevated incidences of TTP, about 1 in 1600 sufferers handled. In distinction, clopidogrel induced TTP has solely been famous in a couple of case experiences [7]. It has been reported by a pharmaceutical provider that the speed of clopidogrel induced TTP is about 12 in 1 million sufferers receiving the medicine [8].

The mechanism of motion in clopidogrel induced TTP differs from what is generally seen. In distinction to low ADAMTS-13 secondary to an autoantibody response, there’s regular protease exercise in circumstances the place clopidogrel is concerned, as seen in our affected person [9]. A research by Bennet et al exploring the totally different mechanism of thienopyridine related TTP, 75% of sufferers that obtained clopidogrel are discovered to have an ADAMTS-13 degree>15% on the time of analysis of TTP. The precise mechanism by which clopidogrel induces TTP has not been effectively studied. A idea of endothelial cell wall harm has been launched. Due to regular ranges of ADAMTS-13, endothelial cell wall harm permits the secretion of those giant multimers of VWF, which have been studied in mouse fashions, inducing TTP [7]. The timeline for clopidogrel induced TTP additionally differs from different medicine induced TTP’s. Indicators of TTP are seen inside a 2 week of receiving clopidogrel, which is in distinction to different thienopyridines through which TTP occurred inside 2-12 weeks of medicine administration [10]. This affected person began presenting with TTP about 9 days after clopidogrel administration. This additionally strengthens the notion that sufferers identified with TTP inside a brief quantity can not permit for auto antibodies to kind in opposition to ADAMSTS-13, permitting one other mechanism to trigger TTP. Due to regular ADAMTS-13 ranges, the analysis of TTP is primarily clinically based mostly on symptomology and lab values (Figures 1 & 2).


Therapy for TTP needs to be began as quickly as presumably secondary to the excessive mortality related to TTP. As a result of clopidogrel induced TTP may be very uncommon, administration is especially based mostly on case experiences and that of routine therapy for TTP. Clopidogrel needs to be instantly discontinued and plasma alternate remedy needs to be thought of instantly. Survival amongst sufferers who obtained TTP was about 70% for these sufferers who obtained plasma alternate [9]. Plasma alternate remedy ought to proceed till platelet depend is over 150 thousand for no less than 3 days. Excessive dose steroids also needs to be began on the time of analysis and tapered as soon as affected person has a platelet depend that has plateau to acceptable ranges [9]. Our affected person has obtained 7 cycles of plasma alternate remedy with enchancment in platelet depend to above 150 after day 4. Our case demonstrates the totally different mechanism that clopidogrel undergoes to trigger TTP then what has extensively been studied.

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