II. Indications

  1. Patients at risk for Heparin Induced Thrombocytopenia
    1. Percutaneous Coronary Intervention (PCI)
    2. Unstable Angina or NSTEMI while awaiting PCI (off label)

III. Mechanism

  1. Hirudin Direct Thrombin Inhibitor
    1. Bivalent peptide derivatives from Salivary Gland of medicinal leaches

IV. Dosing

  1. Coadminister with Aspirin 325 mg orally daily
  2. Percutaneous Coronary Intervention (PCI) for patients at risk for HIT
    1. Bolus: 0.75 mg/kg IV prior to PCI
    2. Next: 1.75 mg/kg/hour until PCI completed and for up to 4 hours after PCI
      1. Decrease to 1 mg/kg/hour if Creatinine Clearance <30 ml/min
      2. Decreased to 0.23 mg/kg/hour if on Hemodialysis
    3. Maintenance: 0.2 mg/kg/hour for up to 20 hours
  3. Unstable Angina or NSTEMI while awaiting PCI (off label)
    1. Coadminister with Dual Antiplatelet Therapy (e.g. Aspirin and Ticagrelor)
    2. May be used with Glycoprotein IIB/IIIA Inhibitor
    3. Bolus: 0.1 mg/kg IV
    4. Maintenance: 0.25 mg/kg/hour until PCI

V. Safety

  1. Pregnancy Category B
  2. Unknown safety in Lactation

VI. Adverse Effects

  1. Major Bleeding
  2. Allergic Reaction
    1. Serious Allergic Reactions including Anaphylaxis may occur with Hirudins
    2. Highest risk on Hirudin re-exposure or in GFR <30 ml/min

VII. Drug Interactions

  1. Warfarin
    1. INR levels are inaccurate while on Bivalirudin
    2. Monitor Warfarin coagulation with Activated Clotting Time (ACT)

IX. References

  1. Hamilton (2020) Tarascon Pocket Pharmacopoeia
  2. Berlioz (2023) Bivalirudin, StatPearls, Treasure Island, FL
    1. https://www.ncbi.nlm.nih.gov/books/NBK557823/

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