When to use bivalirudin (Angiomax) in patients?

From the Guidelines

Bivalirudin should be used as an anticoagulant during percutaneous coronary interventions (PCIs) in patients with acute coronary syndromes or heparin-induced thrombocytopenia (HIT), with a standard dosing of 0.75 mg/kg intravenous bolus followed by a 1.75 mg/kg/hour infusion, as it offers a more predictable anticoagulant response and reduced rates of bleeding complications, as supported by the most recent guidelines 1.

Indications for Bivalirudin Use

• Patients with acute coronary syndromes undergoing PCI
• Patients with heparin-induced thrombocytopenia (HIT) who require anticoagulation
• Patients at high risk of bleeding complications

Advantages of Bivalirudin

• More predictable anticoagulant response
• Shorter half-life (25 minutes)
• Reduced rates of bleeding complications
• Directly inhibits thrombin, preventing fibrin formation and platelet activation

Dosing and Administration

• Standard dosing: 0.75 mg/kg intravenous bolus followed by a 1.75 mg/kg/hour infusion
• Dosing adjustment for HIT patients based on activated partial thromboplastin time (aPTT)
• Renal dose adjustment necessary for patients with impaired kidney function
• Monitoring involves activated clotting time (ACT) measurements, with target values of 300-350 seconds during PCI procedures

Evidence Supporting Bivalirudin Use

• The 2021 ACC/AHA/SCAI guideline for coronary artery revascularization recommends bivalirudin as an alternative to unfractionated heparin (UFH) for patients undergoing PCI 1
• The EUROMAX trial demonstrated the superiority of bivalirudin over UFH in reducing bleeding complications, although with a higher risk of acute stent thrombosis 1
• Meta-analyses have consistently confirmed the benefit of bivalirudin in reducing bleeding rates, although with a higher risk of acute stent thrombosis 1

From the FDA Drug Label

Bivalirudin for Injection is indicated for use as an anticoagulant for use in patients undergoing percutaneous coronary intervention (PCI) including patients with heparin-induced thrombocytopenia and heparin-induced thrombocytopenia and thrombosis syndrome.

Bivalirudin (Angiomax) should be used in patients undergoing percutaneous coronary intervention (PCI), including those with:

• Heparin-induced thrombocytopenia
• Heparin-induced thrombocytopenia and thrombosis syndrome 2 2 2

From the Research

Indications for Bivalirudin Use

• Bivalirudin is indicated for anticoagulation during percutaneous coronary intervention (PCI), particularly in patients with unstable angina pectoris undergoing percutaneous transluminal coronary angioplasty (PTCA) 3, 4.
• It is also used in patients with heparin-induced thrombocytopenia (HIT) or HIT with thrombosis syndrome (HITTS) undergoing PCI 3, 5.
• Bivalirudin can be used as an alternative to heparin plus planned glycoprotein IIb/IIIa inhibition in patients undergoing urgent or elective PCI, especially in those with a high risk of bleeding complications 4.

Patient Populations

• Bivalirudin is effective in patients undergoing PCI with provisional use of glycoprotein IIb/IIIa antagonist therapy 3, 4.
• It is also used in patients with acute coronary syndrome (ACS) who are planned for an invasive treatment strategy 6.
• In patients with chronic kidney disease, dosage adjustments may be necessary due to the increased risk of bleeding complications 7.

Dosage and Administration

• The dosage of bivalirudin may need to be adjusted in patients with renal impairment, particularly those requiring dialysis treatment 7.
• Bivalirudin is administered as an intravenous bolus followed by a continuous infusion, with the dose and duration of infusion depending on the specific clinical scenario 3, 5.