Challenges in monitoring and titration of argatroban versus unfractionated heparin in extracorporeal membrane oxygenation.
5 affiliations
- 1Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria.
- 2Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria.
- 3Division of Gastroenterology and Hepatology, Department of Medicine III, Intensive Care Unit 13H1, Medical University of Vienna, Vienna, Austria.
- 4Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
- 5Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
Abstract
Objectives
Anticoagulation during extracorporeal membrane oxygenation (ECMO) remains challenging. Direct thrombin inhibitors such as argatroban are increasingly proposed as alternatives to unfractionated heparin (UFH). We sought to characterize the dose titration and monitoring reliability of argatroban compared with UFH in adult patients who received ECMO.Methods
This prespecified subanalysis of a randomized controlled pilot trial (2021-2024) included 40 adults on venovenous or venoarterial ECMO randomized to argatroban (target diluted thrombin time 0.6-0.8 μg/mL; n = 20) or UFH (target anti-factor Xa 0.2-0.3 IU/mL; n = 20). The primary outcome was the pooled proportion of measurements within the therapeutic target range. Secondary outcomes included dose requirements, time to target, dose-assay correlations, and platelet count trajectories.Results
Patients who were treated with argatroban achieved therapeutic targets significantly less often than those receiving UFH (38% vs 51% of pooled active measurements; P < .001). The median argatroban dose required to reach the initial target was 0.40 μg/kg/min (interquartile range, 0.34-0.49). Correlations between anticoagulant dose and monitored effect were weak-to-moderate for both agents (repeated measures correlation coefficient = 0.29 for argatroban vs diluted thrombin time, and repeated measures correlation coefficient = 0.31 for UFH vs anti-Xa). Both groups experienced a comparable decrease in platelet counts.Conclusions
In this hypothesis-generating subanalysis, patients receiving argatroban achieved therapeutic targets less reliably than those receiving UFH. However, this variability likely reflects challenges in dosing strategy optimization and differing target stringencies rather than intrinsic pharmacokinetic instability of the drug.
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BibTeX
@article{nagler2026challenges,
title = {{Challenges in monitoring and titration of argatroban versus unfractionated heparin in extracorporeal membrane oxygenation.}},
author = {Bernhard Nagler and Peter Schellongowski and Peter Quehenberger and Alexander Hermann and Mathias Schneeweiß-Gleixner and Elisabeth Lobmeyr and Michael Schwameis and Ludwig Traby and Nina Buchtele and Thomas Staudinger},
journal = {JTCVS open},
year = {2026},
month = aug,
doi = {10.1016/j.xjon.2026.102056},
url = {https://europepmc.org/article/MED/42948445},
note = {CC BY},
}
RIS
TY - JOUR
TI - Challenges in monitoring and titration of argatroban versus unfractionated heparin in extracorporeal membrane oxygenation.
AU - Bernhard Nagler
AU - Peter Schellongowski
AU - Peter Quehenberger
AU - Alexander Hermann
AU - Mathias Schneeweiß-Gleixner
AU - Elisabeth Lobmeyr
AU - Michael Schwameis
AU - Ludwig Traby
AU - Nina Buchtele
AU - Thomas Staudinger
PY - 2026
DA - 2026/08/18
JO - JTCVS open
DO - 10.1016/j.xjon.2026.102056
UR - https://europepmc.org/article/MED/42948445
AB - Objectives Anticoagulation during extracorporeal membrane oxygenation (ECMO) remains challenging. Direct thrombin inhibitors such as argatroban are increasingly proposed as alternatives to unfractionated heparin (UFH). We sought to characterize the dose titration and monitoring reliability of argatroban compared with UFH in adult patients who received ECMO.Methods This prespecified subanalysis of a randomized controlled pilot trial (2021-2024) included 40 adults on venovenous or venoarterial ECMO randomized to argatroban (target diluted thrombin time 0.6-0.8 μg/mL; n = 20) or UFH (target anti-factor Xa 0.2-0.3 IU/mL; n = 20). The primary outcome was the pooled proportion of measurements within the therapeutic target range. Secondary outcomes included dose requirements, time to target, dose-assay correlations, and platelet count trajectories.Results Patients who were treated with argatroban achieved therapeutic targets significantly less often than those receiving UFH (38% vs 51% of pooled active measurements; P < .001). The median argatroban dose required to reach the initial target was 0.40 μg/kg/min (interquartile range, 0.34-0.49). Correlations between anticoagulant dose and monitored effect were weak-to-moderate for both agents (repeated measures correlation coefficient = 0.29 for argatroban vs diluted thrombin time, and repeated measures correlation coefficient = 0.31 for UFH vs anti-Xa). Both groups experienced a comparable decrease in platelet counts.Conclusions In this hypothesis-generating subanalysis, patients receiving argatroban achieved therapeutic targets less reliably than those receiving UFH. However, this variability likely reflects challenges in dosing strategy optimization and differing target stringencies rather than intrinsic pharmacokinetic instability of the drug.
SN - 2666-2736
ER -