Reply to the comment on “Heparin-induced thrombocytopenia” by Betrosian et al. - The treatment of severe hemorrhage in heparin-induced thrombocytopenia in serious illness

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Sir: We thank Alex Betrosian and colleagues [1] for emphasizing the possibility to treat heparin-induced thrombocytopenia (HIT) complicated by bleeding in a non-anticoagulant and non-prohemostatic manner. Their reported case of isolated HIT with life-threatening bleeding complications during severe thrombocytopenia and concomitant treatment with unfractionated heparin in a severely ill patient stresses the importance of our observation of the occurrence of bleeding complications in HIT in the critically ill [2]. As we have mentioned, the pathogenesis of bleeding in HIT is unclear. The interaction between heparin, platelet factor 4 (PF4), anti-heparin/PF4 antibody, and activated platelets results in a procoagulant state which may lead to arterial and venous thromboembolic complications. It is fascinating that bleeding complications may occur more frequently in critically ill patients with increased severity of disease than in other patients. Is it due to HIT, to the alternative anticoagulant therapy, to the severity of disease, or to a combination of these factors? …