How to manage a patient infected with dengue while on anticoagulant/antiplatelet treatment? THE Dr Antonio Amorim Filhorsummarycardiologist in Sao Paulo, Brazil, takes stock of an increasingly common situation due to the increase in dengue cases across the world.
Dengue fever is considered an endemic disease in several Latin American countries, causing significant public health problems each year. The infection is seasonal, with an increase in cases at certain times of the year.
At the same time, cardiovascular diseases (CVD) remain among the deadliest pathologies in the world, with a high prevalence in adults. The use of anticoagulant and antiplatelet treatments to treat various CVDs (coronary heart disease, atrial fibrillation, valvular heart disease, etc.) is therefore frequent.
One of the characteristic changes in dengue is a drop in platelet levels, which can lead to severe hemorrhagic disease.
One of the characteristic changes in dengue is a drop in platelet levels, which can lead to severe hemorrhagic disease. What to do if the infected person is on anticoagulation/antiaggregation? Here is a summary of how these medications can be managed in dengue patients. [1,2]
Aspirin
Acetylsalicylic acid (ASA) remains a widely used drug in the secondary prophylaxis of coronary and cerebrovascular diseases. There is also an indication for patients who have undergone percutaneous coronary intervention, either electively or after acute coronary syndrome (ACS).
In patients with dengue fever:
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platelets > 50,000: maintain SAA with daily platelet testing;
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platelets between 30 and 50,000: maintain the AAS and perform a daily platelet measurement when the patient is admitted to the hospital;
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Dual antiplatelet therapy
Dual antiplatelet therapy (DAPT, aspirin + clopidogrel or another drug in the same category) is used in patients with coronary artery disease who have recently undergone angioplasty. It is important to know how much time has passed since the stent was implanted.
In patients who have undergone angioplasty with a drug-eluting stent less than 6 months ago and a conventional stent less than a month ago:
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platelets > 50,000: maintain DAPT and perform platelet tests daily;
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platelets between 30 and 50,000: maintain DAPT and perform platelet testing with the patient in the hospital;
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In patients who have undergone angioplasty with a drug-eluting stent for more than 6 months and a conventional stent for more than a month:
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platelets > 50,000: maintain ASA only and perform platelet tests daily;
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platelets between 30 and 50,000: maintain ASA only and perform platelet testing with patient admitted to hospital
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Warfarin
Warfarin is used primarily in patients with valvular heart disease and arrhythmias such as atrial fibrillation (AF). In this case, management depends on the results of tests such as PT (prothrombin activity time). The management of patients with dengue thrombocytopenia who are taking warfarin should be as follows:
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platelets > 50,000: maintain warfarin, monitor PT and perform daily platelet count;
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platelets between 30 and 50,000: hospitalize the patient, replace warfarin with unfractionated heparin as soon as the PT indicates an INR
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Direct oral anticoagulants
Direct-acting oral anticoagulants (DOACs), such as thrombin and antifactor Xa inhibitors, are currently widely used, with one of the main indications being patients with AF. The management of patients with thrombocytopenia due to dengue who are taking DOACs should be as follows:
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Platelets > 50,000: maintain the AOD and perform a daily platelet measurement;
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Platelets between 30 and 50,000: hospitalize the patient, interrupt the DOAC and start using unfractionated heparin 24 hours after the last dose of the interrupted drug.
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Platelets
Management of bleeding
If the patient’s bleeding is considered moderate or severe, immediately suspend antiaggregation/anticoagulation. In addition to stopping treatment, the doctor must follow a specific course of action for each use:
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Double antiplatelet aggregation: administer 01 unit of platelets per 10 kg of weight;
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Warfarin: administer fresh frozen plasma 15 ml/kg until INR reaches 1.5, and vitamin K 10 mg intravenously (or orally);
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Thrombin inhibitors and anti-factor Xa: use specific antidotes (idarucizumab and adexanet alfa). In the absence of these drugs, fresh frozen plasma, prothrombin complex, activated recombinant factor XVII, and tranexamic acid may be used.
This article was originally published on the Portuguese edition of Medscape . It was translated, using several editorial tools, including AI, in the process. The translation was reviewed and adapted by the Editorial team before publication.
