- Indications: Argatroban and bivalirudin can be used in suspected or documented cases of heparin-induced thrombocytopenia. However, rivaroxaban and apixaban are now commonly used instead and are simpler.
- Disadvantages: may increase the risk of bleeding in elderly patients, not as easily reversible as heparin. Discuss with hematology as needed.
Basic dosing algorithms: remember to always consult your local pharmacy to verify dosing.
|
Options |
Argatroban |
Bivalirudin (Angiomaxâ) |
|
Indications |
Prophylaxis or treatment in patients with HIT |
Patients with unstable angina undergoing PTCA Prophylaxis or treatment in patients with HIT |
|
Monitoring |
aPTT Obtain first aPTT two hours after initiating argatroban, then q4h |
aPTT, ACT For PCI patients, obtain ACT 5 minutes and 45 minutes after bolus dose For HIT patients obtain first ACT or aPTT 4 hours after bolus |
|
Effect on INR |
Increases Concomitant warfarin dosing difficult |
Slight increase but much less significant than with argatroban |
|
Therapeutic goal |
aPTT 51-67.9 seconds |
ACT 300-350 seconds or aPTT 51-67.9 seconds |
|
Half-life |
39-51 minutes |
25 minutes |
|
Clearance |
Hepatic clearance Preferred in patients with renal dysfunction |
Renal clearance Dose reduction required with renal impairment |
|
Dosing |
2 mcg/kg/min Maximum dose 10 mcg/kg/min Dosage reduction is required in patients with hepatic impairment (0.5 mcg/kg/min) or who are critically ill (1.0 mcg/kg/min) |
For PCI (REPLACE-2): 0.75 mg/kg bolus, then 1.75 mg/kg/h x 4 h, may continue at 0.2 mg/kg/h for 20h For HIT not associated with PCI: 0.15 mg/kg/h (not FDA approved) Dosage reduction is required with renal function (<60 mL/min) and in patients on CRRT or dialysis |
From UCSF Comprehensive Hemostasis and Antithrombotic Service (CHAS) guidelines, 2013.