Systematic Literature Review of DOACs as Treatment for Confirmed or Suspected Heparin-Induced Thrombocytopenia (HIT)

OBJECTIVE: To analyze available literature on the use of direct oral anticoagulants (DOACs) in the treatment of confirmed or suspected heparin-induced thrombocytopenia (HIT). DATA SOURCES: PubMed and Embase databases were searched through December 16, 2024, to identify studies assessing DOAC use in the treatment of acute confirmed or suspected HIT. STUDY SELECTION AND DATA EXTRACTION: Included studies analyzed use of apixaban, dabigatran, edoxaban, or rivaroxaban in patients with confirmed or suspected HIT. DATA SYNTHESIS: Ten studies including 275 patients met the inclusion criteria. Eight were retrospective cohort studies and 2 were prospective. No randomized control trials were identified. A 4Ts score was reported for 259 patients; an antibody immunoassay was reported for 149 patients; and a serotonin release assay was reported for 109 patients. Eight, 6, and 2 studies reported use of rivaroxaban, apixaban, and dabigatran, respectively. Thrombosis rates ranged from 0% to 8.3%, 0% to 13.7%, and 0% to 2.5% for rivaroxaban, apixaban, and dabigatran respectively. Major bleeding was reported in 1 patient receiving rivaroxaban. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: The 2018 American Society of Hematology HIT guidelines conditionally recommend DOAC use due to very low certainty of effects. Direct oral anticoagulants (DOACs) are an attractive treatment option for acute HIT due to ease of administration and reduced need for monitoring. Analysis of the recently published relevant data can support and guide appropriate use of DOACs in these patients. CONCLUSIONS: This systematic review strengthens previously published evidence that DOACs are likely a safe and effective treatment for confirmed or suspected HIT. Study design, small study size, and varying diagnostic criteria reduce data certainty.