Severe and Prolonged Thrombocytopenia Following Heparin and Apixaban Use: A Case Report and Literature Review

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Abstract
Drug-induced thrombocytopenia can occur in hospitalized patients and complicate their antithrombotic treatment. Several medications can associate thrombocytopenia with immune and non-immune mechanisms. Thrombocytopenia can occur at any time from a few hours to months after a new medication initiation. In this study, we have described the case of a female patient with acute-on-chronic kidney injury following a non-steroidal anti-inflammatory agent use, who developed catheter-related thrombosis and was treated with heparin without any complication for 5 days. She was discharged after 5 days and prescribed to use apixaban 2.5 mg twice daily. However, she was readmitted after 24 hours with fatigue, petechiae, and severe thrombocytopenia (7000/mm3). The workup was negative for other reasons of thrombocytopenia. With a possible diagnosis of drug-related thrombocytopenia, apixaban was discontinued. Following the treatment with the intravenous immunoglobulin, her platelet counts increased and stabilized around 40-50,000/mm3. Anticoagulation was thus continued with adjusted doses of rivaroxaban (10-15 mg/day). 17 days after apixaban discontinuation and treatment with prednisolone, her platelet count increased to 108,000/mm3. With reference to this case, a brief review on refractory heparin-induced thrombocytopenia and the association of direct oral anticoagulants with thrombocytopenia is presented.

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