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Intentional overdose with tinzaparin: management dilemmas
Iliana Balla1, Ioasaf Karafotias1, Constantinos Christopoulos1
1First Department of Internal Medicine, "Amalia Fleming" General Hospital, Athens, Greece.
The Journal of Emergency Medicine
|October 3, 2013
Summary
Massive tinzaparin overdose did not require active treatment in the absence of bleeding. Protamine sulfate failed to rapidly normalize coagulation, suggesting clearance is key in managing low-molecular-weight heparin overdose.
Area of Science:
- Pharmacology
- Toxicology
- Hematology
Background:
- Low-molecular-weight heparin (LMWH) is widely used for thromboembolic disease prophylaxis and treatment.
- While generally safe, LMWH overdose can lead to hemorrhage and is only partially reversible with protamine.
- Management of LMWH overdose requires clear guidelines due to limited data.
Observation:
- A case of massive tinzaparin overdose (280,000 IU) via self-injection was reported.
- The patient presented with unrecordable activated partial thromboplastin time (APTT) but no active bleeding.
- Protamine sulfate administration did not rapidly correct coagulation parameters.
Findings:
- Coagulation parameters normalized over 40-50 hours, indicating tinzaparin clearance rather than protamine neutralization.
- Despite the massive overdose, no significant hemorrhagic complications occurred.
- Conventional protamine doses were ineffective in rapidly reversing the effects of the overdose.
Implications:
- In cases of massive LMWH overdose without hemorrhage, active treatment may not be necessary.
- Clinical outcomes suggest that the body's natural clearance mechanisms are crucial in managing LMWH overdose.
- This case highlights the limitations of protamine in neutralizing large doses of LMWH.
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