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Coronary Artery Disease
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
Unless contraindicated, such as by active bleeding, a low molecular weight heparin (LMWH), unfractionated heparin, or bivalirudin are usually given. Unfractionated heparin requires dosing every 6 hours in order to achieve the target activated partial thromboplastin time (aPTT). The LMWHs have lower risks for heparin-induced thrombocytopenia, better bioavailability, and are given via simple weight-based doses that do not require monitoring aPTT or dose titration. For patients with known or suspected occurrences of heparin-induced thrombocytopenia, bivalirudin is preferred. A glycoprotein IIb/IIIa inhibitor is considered during PCI if lesions are of high risk, such as when there is no reflow or a high thrombus burden. Drug choice is based on availability, cost, and familiarity, and options with equivalent effectiveness include abciximab, eptifibatide, and tirofiban.
Current status of fibrinolytic therapy
Published in K Sarat Chandra, AJ Swamy, Acute Coronary Syndromes, 2020
Saubhik Kanjilal, Soumitra Kumar
Bivalirudin is a direct thrombin inhibitor. This agent showed a reduction of reinfarction when 48 hours infusion of bivalirudin was compared with UFH after thrombolysis with streptokinase. A non-significant increase in non-cerebral haemorrhage was seen. Interestingly, bivalirudin was never tried with a fibrin specific fibrinolytic. Hence, its use after fibrinolysis in the current era is limited (Table 12.3).
Medications for endovascular therapy
Published in Peter A. Schneider, Endovascular Skills: Guidewire and Catheter Skills for Endovascular Surgery, 2019
Argatroban is a small molecule and is a direct thrombin inhibitor. It may be used intravenously in patients with heparin-induced thrombocytopenia and is US Food and Drug Administration approved for that purpose. It is metabolized in the liver and its half-life is 50 minutes. It may be used in patients with renal dysfunction and can be monitored using partial thromboplastin time. Bivalirudin is also a direct thrombin inhibitor. It has an onset of a few minutes and a half-life of a few minutes and there is significant experience with this agent in coronary trials. Bivalirudin may also be used in patients with heparin-induced thrombocytopenia. This medication must be dose-adjusted for patients with renal insufficiency or renal failure.
Extracorporeal membrane oxygenation in critically ill neonatal and pediatric patients with acute respiratory failure: a guide for the clinician
Published in Expert Review of Respiratory Medicine, 2021
Briana L. Scott, Desiree Bonadonna, Caroline P. Ozment, Kyle J. Rehder
While heparin has been the anticoagulant used in ECMO for decades, a small number of centers have moved to primary use of bivalirudin, a direct thrombin inhibitor (DTI) [39]. Bivalirudin is an attractive alternative for several reasons. Unlike heparin, it is not dependent on antithrombin and is able to inhibit both circulating and bound thrombin. Bivalirudin is metabolized mainly via intravascular proteolytic degradation with minimal renal clearance (~20%), making it ideal for use in this patient population who may have underlying organ system dysfunction. Although an available reversal agent is lacking, the half life is short (25–35 minutes) [46,47]. A potential disadvantage to using bivalirudin is the lack of readily available laboratory assays to accurately measure drug effect, which has been a main contributor for bivalirudin’s low use as a primary ECMO anticoagulant. Plasma-diluted thrombin time or ecarin bleeding time, both dedicated DTI assays, are not currently widely available, nor has their efficacy in ECMO been established. While current adult guidelines recommend the use of aPTT (chronic monitoring) or ACT (procedural monitoring) where DTI-specific assays are unavailable, both ACT and aPTT have a curvilinear response to plasma DTI concentration and may not yield accurate results [48,49].
Heparin-induced thrombocytopenia: pathophysiology, diagnosis and treatment
Published in Expert Review of Hematology, 2021
Anne-Mette Hvas, Emmanuel J Favaloro, Maja Hellfritzsch
Bivalirudin, also being a synthetic thrombin inhibitor, is a hirudin analog comprising two hirudin peptide fragments [45]. Bivalirudin has obtained regulatory approval in U.S. for treatment of patients with previous HIT undergoing percutaneous coronary intervention. This approval followed studies on bivalirudin in patients with previous HIT scheduled for percutaneous coronary intervention or cardiopulmonary bypass [46,47]. Beyond this indication, a single-center retrospective cohort study investigated 386 patients with suspected HIT (intermediate to high clinical suspicion) or confirmed HIT and who had received bivalirudin for anticoagulation [48]. At time of diagnosis 223 patients (57.8%) had thrombotic HIT. A new thrombosis was diagnosed in 21 (4.6%) patients while they received bivalirudin, proving an acceptable efficacy of bivalirudin in this population. Major bleeding was found in 7.6% of patients, with the highest risk in critically ill patients [48]. In clinical practice, the benefits of bivalirudin include a very short half-life, only 20% renal elimination and no hepatic metabolization. Moreover, it is monitored by APTT or activated clotting time (ACT), both being widely available.
Current approaches in the treatment of catheter-related deep venous thrombosis in children
Published in Expert Review of Hematology, 2020
Julie Jaffray, Neil Goldenberg
Bivalirudin acts by inhibiting free and clot-bound thrombin and is cleared by renal elimination and proteolytic cleavage [66]. A small, single-institution, retrospective study evaluated 16 children who were treated with bivalirudin for either arterial or venous thrombosis [67]. For 10 subjects, thrombus regression was noted by 72 h and only 1 subject experienced bleeding which was after a urethral catheterization. The UNBLOCK (UtilizatioN of BivaLirudin On Clots in Kids) study was a multicenter dose-finding study of bivalirudin in children aged 6 months to 18 years [68]. Dosing consisted of a bolus dose of 0.125 mg/kg, followed by a continuous infusion at an initial dose of 0.125 mg/kg/h, subsequently adjusted to maintain a goal aPTT of 1.5–2 times baseline. By 72 h, half of the 9 subjects demonstrated thrombus resolution; there were no major bleeds (Table 3).