Acenocoumarol/enoxaparin sodium
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Gangrene and heparin-induced thrombocytopenia and thrombosis syndrome in an elderly patient: case report A 76-year-old man developed gangrene and heparininduced thrombocytopenia and thrombosis syndrome (HITT) during treatment with enoxaparin sodium and acenocoumarol. In September 2004, the man underwent surgery for a hip fracture. Six hours later, he started SC enoxaparin sodium 60 mg/day. Four days later, he commenced acenocoumarol 3 mg/day for recurrent deep vein thromboses [route not stated]. On postoperative day 8, he had pain and swelling in his leg, which rapidly developed to limb gangrene. Ultrasonography revealed acute proximal deep vein thrombosis. A coumarin-related complication was suspected, and acenocoumarol was withdrawn. The man received vitamin K, and his enoxaparin sodium dose was increased to maintain therapeutic anticoagulation. On postoperative day 12, his platelet count decreased to 51 × 109/L. HITT was suspected due to the clinical course; however, tests revealed that antibodies to heparin/platelet factor 4 complexes were negative, while anticardiolipin and lupus anticoagulant antibodies were positive. Enoxaparin sodium therapy was continued, but a necrotic skin lesion developed at the injection sites on day 14. Further tests demonstrated in vitro platelet activation by enoxaparin sodium, leading to a diagnosis of HITT with a coumarininduced limb gangrene. Enoxaparin sodium was withdrawn, and he received hirudin. His symptoms improved, however amputation of two toes was required in November 2004. Subsequently, antiphospholipid antibodies became negative, and he was transitioned to acenocoumarol. Reconstructive surgeries were then performed, with complete wound healing by follow up in October 2010. Olah Z, et al. Coagulation: Cascade!. Lancet 378: 740, No. 9792, 20 Aug 2011. Available from: URL: http://dx.doi.org/10.1016/s0140-6736%2811%2960875-1 803061419 Hungary
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Reactions 15 Oct 2011 No. 1373
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