Bivalirudin

• Type: Anticoagulant (Direct thrombin inhibitor)
• Dosage Forms: powder for injection
• Dosage Strengths: 250mg
• Routes of Administration: IV
• Common Trade Names: Angiomax, Angiox

• Acute MI, adjunct to thrombolysis: 0.25 mg/kg IV bolus + 0.5 mg/kg/hr x 12h, then 0.25 mg/kg/hr x 36h
• PCI Thrombosis prophylaxis: 0.75 mg/kg IV bolus + 1.75 mg/kg/hr IV infusion during procedure + 0.2mg/kg/hr x 4-20h after procedure
• Unstable angina/NSTEMI: 0.1 mg/kg IV bolus + 0.25 mg/kg/hour IV infusion

Safety/efficacy not established

• Pregnancy Rating: B
• Lactation risk: Infant risk cannot be ruled out
• Renal dosing: no adjustment in bolus dosing
  • CrCl 30-59 mL/min: no adjustment in infusion or bolus dose
  • CrCl <30: consider reducing infusion to 1 mg/kg/hr
  • Hemodialysis: Reduce infusion rate to 0.25 mg/kg/hr
• Hepatic dosing:

• Allergy to class/drug
• Active major bleeding

• Half-life: 25 min
• Metabolism: Blood proteases
• Excretion: Renal

• Binds to and inhibits thrombin

• Anticoagulant reversal for life-threatening bleeds

• Allie DE, Lirtzman MD, Wyatt CH, et al, “Bivalirudin as a Foundation Anticoagulant in Peripheral Vascular Disease: A Safe and Feasible Alternative for Renal and Iliac Interventions," J Invasive Cardiol, 2003, 15(6):334-42. [PubMed 12777673]
• Amsterdam EA, Wenger NK, Brindis RG, et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American Association for Clinical Chemistry. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in J Am Coll Cardiol. 2014;64(24):2713-2714]. J Am Coll Cardiol. 2014;64(24):e139-e228. doi: 10.1016/j.jacc.2014.09.017. [PubMed 25260718]
• Angiomax (bivalirudin) [prescribing information]. Princeton, NJ: Sandoz Inc; February 2019.
• Angiomax (bivalirudin) [product monograph]. Mississauga, Ontario, Canada: Sunovion Pharmaceuticals Canada Inc.; September 2016.
• Antman EM, “Should Bivalirudin Replace Heparin During Percutaneous Coronary Interventions?” JAMA, 2003, 289:903-5. [PubMed 12588276]
• Aggarwal A, Sobel BE, and Schneider DJ, “Decreased Platelet Reactivity in Blood Anticoagulated With Bivalirudin or Enoxaparin Compared With Unfractionated Heparin: Implications for Coronary Intervention,” J Thromb Thrombolysis, 2002, 13:161-5. [PubMed 12355033]
• Bittl JA, Chaitman BR, Feit F, et al, “Bivalirudin Versus Heparin During Coronary Angioplasty for Unstable or Postinfarction Angina: Final Report Reanalysis of the Bivalirudin Angioplasty Study,” Am Heart J, 2001, 142:952-9. [PubMed 11717596]
• Bittl JA, Strony J, Brinker JA, et al, “Treatment With Bivalirudin (Hirulog) as Compared With Heparin During Coronary Angioplasty for Unstable or Postinfarction Angina. Hirulog Angioplasty Study Investigators,” N Engl J Med, 1995, 333(12):764-9. [PubMed 7643883]
• Bivalirudin injection [prescribing information]. Deerfield, IL: Baxter Healthcare; May 2018.
• Cuker A, Arepally GM, Chong BH, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv. 2018;2(22):3360-3392. doi: 10.1182/bloodadvances.2018024489. [PubMed 30482768]