II. Indications
- Thrombus Prophylaxis (e.g. DVT Prophylaxis after hip surgery)
- Unstable Angina
- Percutaneous Coronary Intervention (PCI)
- Heparin-Induced Thrombocytopenia
- Atrial Fibrillation
III. Dosing: Hirudins (bivalent peptide derivatives from Salivary Gland of medicinal leaches)
- Lepirudan (Refludan)
- See other references for dosing
-
Bivalirudin (Angiomax)
- Used in Unstable Angina if Heparin contraindicated
- Coadminister with Aspirin
- Initial: 0.75 mg/kg IV bolus
- Later: 1.75 mg/kg/hour for 4 hours
- Maintenance: 0.2 mg/kg/hour for up to 20 hours
-
Desirudin (Ipravask)
- DVT Prophylaxis: 15 mg SQ q12 hours after hip surgery
IV. Dosing: Non-Hirudans (Univalent agents)
-
Dabigatran (Pradaxa)
- See Dabigatran
-
Ximelagatran (Exanta, Exarta)
- No longer available in United States due to hepatotoxicity
-
Argatroban (Acova)
- Initial: 2 mcg/kg/minute
- Maintenance: Adjusted per PTT
V. Pharmacokinetics
- Clearance
- Renal Clearance for Hirudins
- Hepatic Clearance for L-Arginine derivatives
VI. Precautions
-
Allergic Reaction
- Serious Allergic Reactions including Anaphylaxis may occur with Hirudins
- Highest risk on Hirudin re-exposure or in GFR <30 ml/min
- Bleeding complications
- Epidural Hematoma
- High risk if Lumbar Puncture performed while on Direct Thrombin Inhibitors
- Epidural Hematoma
- No antidote for bleeding except for Dabigatran (all recommendations per expert opinion)
- Dabigatran (Pradaxa) has a specific antidote (Praxbind)
- Stop offending agent (most have short Half-Life such as 12-14 hours for Dabigatran)
- Bleeding unlikely due to Direct Thrombin Inhibitor if aPTT <37 seconds and Thrombin Time <25 seconds
- Consider Activated Charcoal if presenting within 2 hours of suspected Overdose ingestion
- Dialysis is unlikely to be beneficial
- Logistics of placing large bore filtered catheters in actively bleeding, coagulopathic patients
- Life threatening bleeding - reversal agents
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Related Studies
| Definition (MSH) | Endogenous factors and drugs that directly inhibit the action of THROMBIN, usually by blocking its enzymatic activity. They are distinguished from INDIRECT THROMBIN INHIBITORS, such as HEPARIN, which act by enhancing the inhibitory effects of antithrombins. |
| Definition (CSP) | endogenous family of proteins belonging to the serpin superfamily that neutralizes the action of thrombin; includes fibrin and antithrombin III. |
| Concepts | Pharmacologic Substance (T121) , Biologically Active Substance (T123) , Amino Acid, Peptide, or Protein (T116) |
| MSH | D000991 |
| SnomedCT | 259742007, 414010005 |
| LNC | LP175677-6 |
| English | Antithrombins, Thrombin Inhibitors, Direct, Direct Antithrombins, Direct Thrombin Inhibitors, Antithrombins, Direct, antithrombin, antithrombins, Antithrombin Proteins, Antithrombin Proteins [Chemical/Ingredient], Direct thrombin inhibitors, Antithrombin, Antithrombin (substance), DTI - direct thrombin inhibitor, Direct thrombin inhibitor (substance), Direct thrombin inhibitor |
| French | Antithrombines, Antithrombiniques directs, Inhibiteurs directs de la thrombine, Anti-thrombines, Antithrombines directes, Antithrombiniques, Anti-thrombiniques |
| German | Direkte Thrombin-Inhibitoren, Direkte Antithrombine, Antithrombine, Direkte Thrombininhibitoren |
| Czech | antithrombiny, přímé inhibitory thrombinu |
| Italian | Antitrombine |
| Spanish | Antitrombinas Directas, Antitrombinas, antitrombina (sustancia), antitrombina, inhibidor directo de trombina (sustancia), inhibidor directo de trombina |
| Russian | ANTITROMBINY, АНТИТРОМБИНЫ |
| Portuguese | Antitrombinas, Antitrombinas Diretas |
| Polish | Antytrombiny |
Ontology: Refludan (C0661608)
| Concepts | Organic Chemical (T109) , Pharmacologic Substance (T121) |
| MSH | C083544 |
| English | Refludan, lepirudin (Refludan), refludan, Hoechst Brand of Lepirudin, Aventis Behring Brand of Lepirudin, Aventis Brand Lepirudin, Aventis Pharma Brand of Lepirudin, Berlex Brand of Lepirudin, Pharmion Brand of Lepirudin, Refludin, Schering Brand of Lepirudin |
Ontology: lepirudin (C0772394)
| Definition (NCI_NCI-GLOSS) | A drug that inhibits blood clotting. It is being studied in cancer treatment. |
| Definition (NCI) | A yeast cell-derived recombinant polypeptide related to the naturally occurring, leech-derived anticoagulant hirudin. Lepirudin directly binds to and inactivates thrombin, producing dose-dependent increases in the activated partial thromboplastin time (aPTT) and prothrombin time (PT). The mechanism of action of this agent is independent of antithrombin III and is not inhibited by platelet factor 4. Natural hirudin, a family of highly homologous isopolypeptides, is produced in trace amounts by the leech Hirudo medicinalis. |
| Definition (PDQ) | A recombinant hirudin, a polypeptide naturally produced by the leech Hirudo medicinalis, derived from yeast cells and a highly specific inhibitor of thrombin. Lepirudin directly binds to thrombin, thereby inactivating the thrombogenic activity of thrombin. This anticoagulant produces dose-dependent increases in activated partial thromboplastin time (aPTT). Its action is independent of antithrombin III and it is not inhibited by platelet factor 4. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=43356&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=43356&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C1839" NCI Thesaurus) |
| Concepts | Pharmacologic Substance (T121) , Amino Acid, Peptide, or Protein (T116) |
| MSH | C083544 |
| SnomedCT | 108995001, 386955005 |
| LNC | LP171615-0 |
| English | Recombinant Hirudin, 1-Leu-2-Thr-63-desulfohirudin, lepirudin, lepirudin (medication), lepirudin (rDNA), LEPIRUDIN, lepirudin [Chemical/Ingredient], lepirudin,recombinant, Lepirudin, Lepirudin (product), Lepirudin (substance) |
| Spanish | lepirudina (producto), lepirudina (sustancia), lepirudina |
Ontology: Hirudins (C1451270)
| Definition (MSH) | Single-chain polypeptides of about 65 amino acids (7 kDa) from LEECHES that have a neutral hydrophobic N terminus, an acidic hydrophilic C terminus, and a compact, hydrophobic core region. Recombinant hirudins lack tyr-63 sulfation and are referred to as 'desulfato-hirudins'. They form a stable non-covalent complex with ALPHA-THROMBIN, thereby abolishing its ability to cleave FIBRINOGEN. |
| Definition (CSP) | active principle in the buccal gland secretion (saliva) of leeches; it acts as an antithrombin and as an antithrombotic agent. |
| Concepts | Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance (T121) |
| MSH | D006629 |
| English | hirudin, Hirudins [Chemical/Ingredient], HIRUDIN, Hirudins |
| Swedish | Hirudiner |
| Czech | hirudiny |
| Finnish | Hirudiinit |
| Russian | GIRUDIN, GIRUDINY, ГИРУДИН, ГИРУДИНЫ |
| Polish | Hirudyny |
| French | Hirudines |
| German | Hirudine |
| Italian | Irudine |
| Portuguese | Hirudinas |
| Spanish | Hirudinas |
