What is the recommended dose of Tirofiban (Aggrastat) for patients undergoing coronary angioplasty or treatment of acute coronary syndrome?

Tirofiban Dosing Recommendations for Coronary Interventions

The recommended dose of Tirofiban (Aggrastat) for patients undergoing coronary angioplasty or treatment of acute coronary syndrome is 25 mcg/kg administered intravenously within 5 minutes as a loading dose, followed by a maintenance infusion of 0.15 mcg/kg/min for up to 18 hours. 1, 2

Standard Dosing for Most Patients

• For patients with normal renal function (creatinine clearance >60 mL/min), the FDA-approved dosing regimen is:

  • Loading dose: 25 mcg/kg IV bolus administered within 5 minutes 1, 2
  • Maintenance dose: 0.15 mcg/kg/min IV infusion for up to 18 hours 1, 2

• This high-dose bolus regimen leads to consistent and rapid inhibition of platelet aggregation during the first hour after initiation of therapy 3

Dose Adjustment for Renal Impairment

• For patients with renal impairment (creatinine clearance ≤60 mL/min), the dose should be reduced:

  • Loading dose: 25 mcg/kg IV bolus (same as standard) 1
  • Maintenance dose: 0.075 mcg/kg/min (50% reduction) 1, 2

• For patients with severe renal impairment (creatinine clearance <30 mL/min), pharmacokinetic modeling suggests:

  • Loading dose: 25 mcg/kg IV bolus (same as standard) 3
  • Maintenance dose: 0.10 mcg/kg/min 3

Alternative Lower-Dose Regimen

• An alternative FDA-approved lower-dose regimen for UA/NSTEMI patients with substantial delay to angiography/PCI (e.g., 48 hours):
  • Loading dose: 0.4 mcg/kg/min for 30 minutes 2
  • Maintenance dose: 0.1 mcg/kg/min 2
  • Continue infusion through angiography and for 12 to 24 hours after angioplasty or atherectomy 2

Clinical Context and Administration

• Tirofiban is indicated to reduce thrombotic cardiovascular events in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) 1

• The drug has a plasma half-life of 1.5 to 2 hours, with platelet function recovering to 50% of baseline within 4 hours after stopping the infusion 2

• Tirofiban can be administered in the same intravenous line as heparin, atropine, dobutamine, dopamine, epinephrine, famotidine, furosemide, lidocaine, midazolam, morphine, nitroglycerin, potassium chloride, and propranolol 1

• Do not administer tirofiban through the same IV line as diazepam 1

Monitoring and Safety Considerations

• Monitor for bleeding complications, which are the most common adverse events associated with tirofiban therapy 1, 4

• Monitor platelet counts beginning about 6 hours after treatment initiation and daily thereafter 1

• If platelet count decreases to <90,000/mm³, monitor to exclude pseudothrombocytopenia; if thrombocytopenia is confirmed, discontinue tirofiban and heparin 1

• Severe but reversible thrombocytopenia has been reported in a small percentage of patients treated with tirofiban 2

• Previous exposure to glycoprotein IIb/IIIa receptor antagonists may increase the risk of developing thrombocytopenia 1

Comparison with Other Glycoprotein IIb/IIIa Inhibitors

• Tirofiban has a more rapid onset of action (within 5 minutes) and is more rapidly reversible (4-6 hours) compared to abciximab 2, 5

• Eptifibatide has a short half-life with platelet function recovering within 2-4 hours after treatment cessation 5

• All three agents (abciximab, double-bolus eptifibatide, and high-bolus dose tirofiban) result in a high degree of platelet inhibition and appear to lead to comparable angiographic and clinical outcomes 2