New Anticoagulants and Antiplatelet Agents
New Anticoagulants and Antiplatelet Agents
Bivalirudin is a synthetic peptide analog of hirudin and a bivalent DTI. It is approved for use in patients undergoing percutaneous coronary intervention (PCI) with provisional use of glycoprotein IIb/IIIa inhibitors, patients with or at risk of heparin-induced thrombocytopenia, or in patients with unstable angina undergoing percutaneous transluminal coronary angioplasty.
Administered intravenously, bivalirudin achieves an immediate peak plasma concentration with a half-life of 22 min. Approximately 20% of unchanged bivalirudin is renally excreted, and the remainder undergoes intracellular proteolysis. Thus, particular consideration should be given to patients with severe renal impairment or in dialysis-dependent patients. Current recommendations are to adjust the dose for renal impairment in patients with a CrCl of 10–29 ml/min undergoing PCI and in patients with a CrCl<60 ml/min being treated for heparin-induced thrombocytopenia. Current manufacturer recommendations state that dosing modifications are not necessary in patients with hepatic impairment.
Reversal Agents There are presently no reversal agents that can be used in the event of an acute bleed in patients on bivalirudin. Current guidelines suggest that modified ultrafiltration and hemodialysis may facilitate the removal of bivalirudin with modified ultrafiltration (removal of between 45–69% depending on the filter type) being superior to hemodialysis (removal of 25%). Recombinant factor VII can be administered at a dose of 90 mcg/kg intravenously. Lastly, blood products such as fresh frozen plasma or cryoprecipitate can be given to work as a competitor to displace bivalirudin from thrombin.
Owing to its short half-life, an infusion of bivalirudin needs only to be discontinued before induction of anesthesia in a patient with normal renal function.
Bivalirudin (Angiomax)
Bivalirudin is a synthetic peptide analog of hirudin and a bivalent DTI. It is approved for use in patients undergoing percutaneous coronary intervention (PCI) with provisional use of glycoprotein IIb/IIIa inhibitors, patients with or at risk of heparin-induced thrombocytopenia, or in patients with unstable angina undergoing percutaneous transluminal coronary angioplasty.
Pharmacodynamics
Administered intravenously, bivalirudin achieves an immediate peak plasma concentration with a half-life of 22 min. Approximately 20% of unchanged bivalirudin is renally excreted, and the remainder undergoes intracellular proteolysis. Thus, particular consideration should be given to patients with severe renal impairment or in dialysis-dependent patients. Current recommendations are to adjust the dose for renal impairment in patients with a CrCl of 10–29 ml/min undergoing PCI and in patients with a CrCl<60 ml/min being treated for heparin-induced thrombocytopenia. Current manufacturer recommendations state that dosing modifications are not necessary in patients with hepatic impairment.
Reversal Agents There are presently no reversal agents that can be used in the event of an acute bleed in patients on bivalirudin. Current guidelines suggest that modified ultrafiltration and hemodialysis may facilitate the removal of bivalirudin with modified ultrafiltration (removal of between 45–69% depending on the filter type) being superior to hemodialysis (removal of 25%). Recombinant factor VII can be administered at a dose of 90 mcg/kg intravenously. Lastly, blood products such as fresh frozen plasma or cryoprecipitate can be given to work as a competitor to displace bivalirudin from thrombin.
Recommended Withholding Period Before Endoscopic Procedures
Owing to its short half-life, an infusion of bivalirudin needs only to be discontinued before induction of anesthesia in a patient with normal renal function.
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