Weight-Based Dosing for Bivalirudin in PCI
The recommended weight-based dosing for bivalirudin in patients undergoing percutaneous coronary intervention (PCI) is a 0.75 mg/kg intravenous bolus followed by a 1.75 mg/kg/hour infusion for the duration of the procedure. 1
Standard Dosing Regimen
- Bivalirudin is administered as a 0.75 mg/kg IV bolus, followed immediately by a 1.75 mg/kg/hour IV infusion for the duration of the PCI procedure 2, 1
- Five minutes after the bolus dose, an activated clotting time (ACT) should be performed and an additional bolus of 0.3 mg/kg should be given if needed 1
- For patients who have previously received unfractionated heparin (UFH), wait 30 minutes before administering the bivalirudin bolus 2
Special Considerations
- Renal Impairment: For patients with creatinine clearance <30 mL/min, reduce the infusion dose to 1 mg/kg/hour 2, 1
- ST-Elevation MI (STEMI): Consider extending the duration of infusion post-procedure up to 4 hours in STEMI patients 1, 2
- Post-PCI: After cessation of the 1.75 mg/kg/hour infusion, a reduced infusion dose of 0.25 mg/kg/hour may be continued for 4-12 hours as clinically necessary in STEMI patients 2
Pharmacokinetics and Monitoring
- Bivalirudin has a half-life of approximately 25 minutes in patients with normal renal function 2, 1
- Coagulation times return to baseline approximately 1 hour following cessation of bivalirudin administration 1
- Unlike unfractionated heparin, routine ACT monitoring is not required for bivalirudin, though an ACT is recommended 5 minutes after the initial bolus 1
- Bivalirudin is primarily cleared by proteolytic cleavage, with approximately 20% excreted unchanged via the kidneys 3
Clinical Evidence and Guidelines
- Bivalirudin is a Class I recommendation (Level of Evidence B) in both American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines for use in PCI 2
- Bivalirudin is particularly recommended over UFH with glycoprotein IIb/IIIa inhibitors in patients at high risk of bleeding (Class IIa, Level of Evidence B) 2
- The weight-based dosing regimen has been validated in multiple large clinical trials including HORIZONS-AMI, EUROMAX, and HEAT 2
Important Considerations and Caveats
- Bivalirudin increases the risk of acute stent thrombosis in STEMI patients undergoing primary PCI compared to heparin with glycoprotein IIb/IIIa inhibitors (1.3% vs 0.3%) 2
- To mitigate this risk, adequate loading with antiplatelet agents (particularly 600 mg of clopidogrel) is recommended when using bivalirudin 2
- Bivalirudin is contraindicated in patients with active major bleeding or hypersensitivity to the drug or its components 1
- When switching from heparin to bivalirudin, a 30-minute waiting period is recommended to avoid "stacking" of anticoagulants 2
This weight-based dosing regimen has been extensively studied and is supported by both FDA labeling and major cardiology society guidelines, providing effective anticoagulation while potentially reducing bleeding complications compared to heparin plus glycoprotein IIb/IIIa inhibitors.