■Telofiban是一类含有RGD序列的小分子非肽酪氨酸衍生物。它是目前在中国销售的唯一的血小板表面糖蛋白(GP)IIb/IIIa受体拮抗剂(GPI)。ST段抬高型心肌梗死(STEMI)患者接受经皮冠状动脉介入治疗(PCI),血栓负荷较重,术后静脉注射替罗非班可预防因冠状动脉突然闭塞引起的心肌缺血并发症。随着替罗非班临床应用的增多,替罗非班诱导的血小板减少相关不良反应的数量逐渐增加。尽管如此,其中大多数在首次使用后出现血小板减少症。我们报告了一例替罗非班重复使用后非常严重的血小板减少症。
■一名65岁的汉族男子,170厘米高,体重85公斤,和29.4BMI,13年前患有脑梗塞,左右侧肢体运动障碍。住院前五天,患者接受了PCI治疗,并植入了3个支架.手术后,给予抗血小板替罗非班和那曲肝素钙,未发现血小板减少症。由于前降支,患者仍保留80%的狭窄,并计划在半个月后再次进行PCI。有高血压病史的病人,2型糖尿病,糖尿病肾病,脑梗死通常服用100毫克阿司匹林和75毫克氯吡格雷,抗血小板治疗,既往史:无食物药物过敏史。出院后一天,患者突然感到胸闷和喘息。实验室显示超敏肌钙蛋白2.85ng/ml(正常0-0.0268ng/ml),入院心电图显示I导联ST-T改变,aVL,V5-V6.住院第6天,进行了PCI,在前降支开口的近端植入了支架,和替罗非班(10ug/kg,3分钟推注,术后给予0.1ug/kg/min)抗血小板治疗。替罗非班输注后约10分钟,病人突然发抖,伴有抽搐,伴随着体温升高(高达39.4°C),伴有鼻出血和镜下血尿。紧急血液检查显示,血小板降至1×109/L,立即停止替罗非班和阿司匹林,保留了氯吡格雷的抗血小板治疗。输注甲基强的松龙琥珀酸钠和丙种球蛋白后,病人的血小板逐渐恢复,病人七天后顺利出院,情况稳定。
■这种情况是典型的由替罗非班重复使用引起的严重血小板减少症。这个案例可能会提供新的见解:1.首次使用替罗非班后没有血小板减少症的患者在再次接触替罗非班后可能仍有极严重的血小板减少症。常规血小板计数监测和早期识别血小板减少是必不可少的环节。2.再次接触替罗非班引起的血小板减少症可能起病更快,更深的程度,并且由于首次接触替罗非班后保留的抗体而导致恢复较慢;3.严重血小板减少症患者可能不需要进行血小板输注;4.免疫抑制剂有助于抑制身体的免疫反应,促进血小板恢复,当血小板升高时可以减少或停用,可能是安全的;5.替罗非班用于PCI后,如果患者没有明显的出血事件,继续氯吡格雷的维持剂量可能是安全的。
UNASSIGNED: Telofiban is a class of small molecule non-peptide tyrosine derivatives containing RGD sequences. It is the only platelet surface glycoprotein (GP) IIb/IIIa receptor antagonist (GPI) currently marketed in China. In patients with ST-segment elevation myocardial infarction(STEMI) who receive percutaneous coronary intervention (PCI) with a heavy thrombotic load, postoperative intravenous tirofiban can prevent complications of myocardial ischemia due to sudden coronary artery occlusion. With the increase in the clinical use of tirofiban, the number of adverse reactions related to thrombocytopenia induced by tirofiban has gradually increased. Still, most of them have thrombocytopenia after the first use. We report one
case of very
severe thrombocytopenia following the reuse of tirofiban.
UNASSIGNED: A 65-year-old man of Han nationality, 170 cm in height, 85 kg in weight, and 29.4 BMI, suffered from cerebral infarction 13 years ago and left with right limb movement disorder. Five days before this hospitalization, the patient underwent PCI, and three stents were implanted. After the operation, anti-platelet tirofiban and nadroparin calcium were given, and no thrombocytopenia was found. The patient still retains 80% stenosis due to anterior descending branches and plans to undergo PCI again half a month later. The patient with a history of hypertension, type 2 diabetes, diabetic nephropathy, and cerebral infarction usually took 100 mg of aspirin and 75 mg of clopidogrel, antiplatelet therapy, and had no history of food and drug allergy. One day after discharge, the patient suddenly felt chest tightness and wheezing. The laboratory showed hypersensitivity troponin 2.85 ng/ml (normal 0-0.0268 ng/ml), and the admission ECG showed ST-T changes in leads I, aVL, V5-V6. On the 6th day of hospitalization, PCI was performed, a stent was implanted in the proximal section of the anterior descending branch opening, and tirofiban(10 ug/kg, 3 min bolus, then 0.1 ug/kg/min) antiplatelet therapy was given after surgery. About 10 min after the tirofiban infusion, the patient suddenly shivered, accompanied by convulsions, accompanied by elevated body temperature (up to 39.4°C), accompanied by epistaxis and microscopic hematuria. An urgent blood test showed that the platelets dropped to 1 × 109/L, tirofiban and aspirin stopped immediately, and the antiplatelet therapy of clopidogrel was retained. After infusion of methylprednisolone sodium succinate and gamma globulin, the patient\'s platelets gradually recovered, and the patient was successfully discharged seven days later in stable condition.
UNASSIGNED: This
case is typical of
severe thrombocytopenia caused by reusing tirofiban. This
case may provide new insights into: 1. Patients who did not have thrombocytopenia after the first use of tirofiban may still have extremely
severe thrombocytopenia after re-exposure to tirofiban. Routine platelet count monitoring and early identification of thrombocytopenia are the essential links. 2. Thrombocytopenia caused by re-exposure to tirofiban may have a faster onset, deeper degree, and slower recovery due to antibodies retained after the first exposure to tirofiban; 3. Platelet transfusions may not be necessary for patients with
severe thrombocytopenia; 4. Immunosuppressants help suppress the body\'s immune response, promote platelet recovery, and can be reduced or discontinued when platelets rise and may be safe; 5. After tirofiban for PCI, continuing the maintenance dose of clopidogrel may be safe if the patient has no significant bleeding events.