bivalirudin (Rx)

Brand and Other Names:Angiomax, Angiomax RTU
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injection, powder for reconstitution

  • 250mg/vial

injection, ready-to-use solution

  • 5mg/mL (250mg/50mL; 500mg/100mL)

Percutaneous Coronary Intervention

Use as anticoagulant in heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia and thrombosis (HITT) syndrome

Has only been studied in patients receiving concomitant aspirin

0.75 mg/kg IV bolus, and then IMMEDIATELY 1.75 mg/kg/hr IV infusion for duration of procedure

Obtain activated clotting time (ACT) 5 min after administering the bolus dose; an additional IV bolus of 0.3 mg/kg should be given if needed

Consider extended duration of infusion following PCI at 1.75 mg/kg/hr for up to 4 hr postprocedure in patients with ST segment elevation MI (STEMI)

Dosage Modifications

Renal impairment

  • Bolus Dose
    • No reduction required for any degree of renal impairment
  • IV infusion
    • Moderate (CrCl 30-59 mL/min): 1.75 mg/kg/hr
    • Severe (CrCl <30 mL/min): 1 mg/kg/hr
    • Hemodialysis: 0.25 mg/kg/hr

Hepatic impairment

  • No dosage adjustment required

Dosing Considerations

Safety and effectiveness have not been established in patients with acute coronary syndromes who are not undergoing PTCA or PCI

Heparin-induced Thrombocytopenia (Off-label)

Initial: 0.15-0.2 mg/kg/hr IV; adjust to aPTT 1.5-2.5 times baseline value  

Anticoagulation & Risk of HIT (Orphan)

Orphan designation for use as an anticoagulant in patients with or at risk of heparin-induced thrombocytopenia/heparin-induced thrombocytopenia thrombosis syndrome

Orphan sponsor

  • The Medicines Company; 8 Sylvan Way; Parsippany, NJ 07054

Safety and efficacy not established

Next:

Interactions

Interaction Checker

and bivalirudin

No Results

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    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

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            Contraindicated (3)

            • defibrotide

              defibrotide increases effects of bivalirudin by pharmacodynamic synergism. Contraindicated. Coadministration of defibrotide is contraindicated with antithrombotic/fibrinolytic drugs. This does not include use for routine maintenance or reopening of central venous lines.

            • mifepristone

              mifepristone, bivalirudin. Other (see comment). Contraindicated. Comment: Mifepristone may lead to excessive post abortion bleeding in pts. on anticoagulant therapy.

            • prothrombin complex concentrate, human

              bivalirudin, prothrombin complex concentrate, human. pharmacodynamic synergism. Contraindicated.

            Serious - Use Alternative (62)

            • abciximab

              bivalirudin, abciximab. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • amobarbital

              amobarbital decreases effects of bivalirudin by increasing metabolism. Avoid or Use Alternate Drug.

            • anagrelide

              bivalirudin, anagrelide. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • antithrombin alfa

              antithrombin alfa and bivalirudin both increase anticoagulation. Avoid or Use Alternate Drug.

            • antithrombin III

              antithrombin III and bivalirudin both increase anticoagulation. Avoid or Use Alternate Drug.

            • apixaban

              bivalirudin and apixaban both increase anticoagulation. Avoid or Use Alternate Drug.

            • argatroban

              argatroban and bivalirudin both increase anticoagulation. Avoid or Use Alternate Drug.

            • azithromycin

              azithromycin increases effects of bivalirudin by decreasing metabolism. Avoid or Use Alternate Drug.

            • bazedoxifene/conjugated estrogens

              bazedoxifene/conjugated estrogens decreases effects of bivalirudin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • bemiparin

              bemiparin and bivalirudin both increase anticoagulation. Avoid or Use Alternate Drug.

            • butabarbital

              butabarbital decreases effects of bivalirudin by increasing metabolism. Avoid or Use Alternate Drug.

            • butalbital

              butalbital decreases effects of bivalirudin by increasing metabolism. Avoid or Use Alternate Drug.

            • cefamandole

              cefamandole increases effects of bivalirudin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • cefazolin

              cefazolin increases effects of bivalirudin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • cefdinir

              cefdinir increases effects of bivalirudin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity.

            • cefditoren

              cefditoren will increase the level or effect of bivalirudin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

            • cefotetan

              cefotetan increases effects of bivalirudin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity.

            • cefoxitin

              cefoxitin will increase the level or effect of bivalirudin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

            • cefpodoxime

              cefpodoxime will increase the level or effect of bivalirudin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

            • ceftriaxone

              ceftriaxone will increase the level or effect of bivalirudin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

            • cefuroxime

              cefuroxime will increase the level or effect of bivalirudin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

            • cilostazol

              bivalirudin, cilostazol. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • clarithromycin

              clarithromycin increases effects of bivalirudin by decreasing metabolism. Avoid or Use Alternate Drug.

            • clopidogrel

              bivalirudin, clopidogrel. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • conjugated estrogens

              conjugated estrogens decreases effects of bivalirudin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • dalteparin

              bivalirudin and dalteparin both increase anticoagulation. Avoid or Use Alternate Drug.

            • dipyridamole

              bivalirudin, dipyridamole. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • edoxaban

              edoxaban, bivalirudin. Either increases toxicity of the other by anticoagulation. Avoid or Use Alternate Drug. Both drugs have the potential to cause bleeding, monitor closely. Promptly evaluate any signs or symptoms of blood loss. Long-term concomitant treatment with edoxaban and other anticoagulants is not recommended. Short-term coadministration may be needed for patients transitioning to or from edoxaban.

            • enoxaparin

              bivalirudin and enoxaparin both increase anticoagulation. Avoid or Use Alternate Drug.

            • eptifibatide

              bivalirudin, eptifibatide. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • erythromycin base

              erythromycin base increases effects of bivalirudin by decreasing metabolism. Avoid or Use Alternate Drug.

            • erythromycin ethylsuccinate

              erythromycin ethylsuccinate increases effects of bivalirudin by decreasing metabolism. Avoid or Use Alternate Drug.

            • erythromycin lactobionate

              erythromycin lactobionate increases effects of bivalirudin by decreasing metabolism. Avoid or Use Alternate Drug.

            • erythromycin stearate

              erythromycin stearate increases effects of bivalirudin by decreasing metabolism. Avoid or Use Alternate Drug.

            • estradiol

              estradiol decreases effects of bivalirudin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • estrogens conjugated synthetic

              estrogens conjugated synthetic decreases effects of bivalirudin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • estropipate

              estropipate decreases effects of bivalirudin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • Factor X, human

              bivalirudin will decrease the level or effect of Factor X, human by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Based on the mechanism of action, Factor X is likely to be counteracted by direct and indirect Factor Xa inhibitors.

            • fondaparinux

              bivalirudin and fondaparinux both increase anticoagulation. Avoid or Use Alternate Drug.

            • heparin

              bivalirudin and heparin both increase anticoagulation. Avoid or Use Alternate Drug.

            • levonorgestrel intrauterine

              levonorgestrel intrauterine, bivalirudin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.

            • levonorgestrel oral

              levonorgestrel oral, bivalirudin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.

            • levothyroxine

              levothyroxine increases effects of bivalirudin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • liothyronine

              liothyronine increases effects of bivalirudin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • mestranol

              mestranol decreases effects of bivalirudin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • pentobarbital

              pentobarbital decreases effects of bivalirudin by increasing metabolism. Avoid or Use Alternate Drug.

            • phenindione

              bivalirudin and phenindione both increase anticoagulation. Avoid or Use Alternate Drug.

            • phenobarbital

              phenobarbital decreases effects of bivalirudin by increasing metabolism. Avoid or Use Alternate Drug.

            • piperacillin

              piperacillin will increase the level or effect of bivalirudin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

            • primidone

              primidone decreases effects of bivalirudin by increasing metabolism. Avoid or Use Alternate Drug.

            • protamine

              bivalirudin and protamine both increase anticoagulation. Avoid or Use Alternate Drug.

            • quinine

              quinine increases effects of bivalirudin by unknown mechanism. Avoid or Use Alternate Drug.

            • roxithromycin

              roxithromycin increases effects of bivalirudin by decreasing metabolism. Avoid or Use Alternate Drug.

            • secobarbital

              secobarbital decreases effects of bivalirudin by increasing metabolism. Avoid or Use Alternate Drug.

            • sulfadiazine

              sulfadiazine increases effects of bivalirudin by decreasing metabolism. Avoid or Use Alternate Drug.

              sulfadiazine increases effects of bivalirudin by plasma protein binding competition. Avoid or Use Alternate Drug.

            • sulfamethoxazole

              sulfamethoxazole increases effects of bivalirudin by decreasing metabolism. Avoid or Use Alternate Drug.

              sulfamethoxazole increases effects of bivalirudin by plasma protein binding competition. Avoid or Use Alternate Drug.

            • sulfisoxazole

              sulfisoxazole increases effects of bivalirudin by decreasing metabolism. Avoid or Use Alternate Drug.

              sulfisoxazole increases effects of bivalirudin by plasma protein binding competition. Avoid or Use Alternate Drug.

            • thyroid desiccated

              thyroid desiccated increases effects of bivalirudin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • tibolone

              tibolone increases effects of bivalirudin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • ticlopidine

              bivalirudin, ticlopidine. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • tirofiban

              bivalirudin, tirofiban. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • warfarin

              bivalirudin and warfarin both increase anticoagulation. Avoid or Use Alternate Drug.

            Monitor Closely (122)

            • acalabrutinib

              acalabrutinib increases effects of bivalirudin by anticoagulation. Use Caution/Monitor. Coadministration of acalabrutinib with antiplatelets or anticoagulants may further increase risk of hemorrhage. Monitor for signs of bleeding and consider the benefit-risk of withholding acalabrutinib for 3-7 days presurgery and postsurgery depending upon the type of surgery and the risk of bleeding.

            • aceclofenac

              bivalirudin and aceclofenac both increase anticoagulation. Modify Therapy/Monitor Closely.

            • acemetacin

              bivalirudin and acemetacin both increase anticoagulation. Modify Therapy/Monitor Closely.

            • agrimony

              bivalirudin and agrimony both increase anticoagulation. Modify Therapy/Monitor Closely.

            • alfalfa

              bivalirudin and alfalfa both increase anticoagulation. Modify Therapy/Monitor Closely.

            • alteplase

              bivalirudin and alteplase both increase anticoagulation. Modify Therapy/Monitor Closely.

            • American ginseng

              bivalirudin and American ginseng both increase anticoagulation. Modify Therapy/Monitor Closely.

            • anamu

              bivalirudin and anamu both increase anticoagulation. Use Caution/Monitor.

            • aspirin

              bivalirudin and aspirin both increase anticoagulation. Modify Therapy/Monitor Closely.

              aspirin, bivalirudin. Either increases toxicity of the other by anticoagulation. Use Caution/Monitor. The need for simultaneous use of low-dose aspirin and anticoagulant or antiplatelet agents are common for patients with cardiovascular disease; monitor closely.

            • aspirin rectal

              bivalirudin and aspirin rectal both increase anticoagulation. Modify Therapy/Monitor Closely.

            • aspirin/citric acid/sodium bicarbonate

              aspirin/citric acid/sodium bicarbonate, bivalirudin. Either increases toxicity of the other by anticoagulation. Use Caution/Monitor. The need for simultaneous use of low-dose aspirin and anticoagulant or antiplatelet agents are common for patients with cardiovascular disease; monitor closely.

              bivalirudin and aspirin/citric acid/sodium bicarbonate both increase anticoagulation. Modify Therapy/Monitor Closely.

            • azapropazone

              azapropazone increases effects of bivalirudin by plasma protein binding competition. Use Caution/Monitor.

            • azathioprine

              azathioprine decreases effects of bivalirudin by unknown mechanism. Use Caution/Monitor.

            • azficel-T

              azficel-T, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Coadministration with anticoagulants or antiplatelets may increase bruising or bleeding at biopsy and/or injection sites; concomitant use not recommended. Decisions regarding continued use or cessation of anticoagulants or antiplatelets should be made by a physician.

            • betrixaban

              bivalirudin, betrixaban. Either increases levels of the other by anticoagulation. Use Caution/Monitor.

            • budesonide

              budesonide, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • capecitabine

              capecitabine increases effects of bivalirudin by unspecified interaction mechanism. Use Caution/Monitor.

            • caplacizumab

              caplacizumab, bivalirudin. Either increases effects of the other by anticoagulation. Use Caution/Monitor.

            • carbamazepine

              carbamazepine decreases levels of bivalirudin by increasing metabolism. Use Caution/Monitor.

            • celecoxib

              bivalirudin and celecoxib both increase anticoagulation. Modify Therapy/Monitor Closely.

            • chitosan

              chitosan increases effects of bivalirudin by Other (see comment). Use Caution/Monitor. Comment: Chitosan can decrease GI absorption of vitamin K, enhancing anticoagulant effects.

            • choline magnesium trisalicylate

              bivalirudin and choline magnesium trisalicylate both increase anticoagulation. Modify Therapy/Monitor Closely.

            • cinnamon

              bivalirudin and cinnamon both increase anticoagulation. Modify Therapy/Monitor Closely.

            • citalopram

              citalopram increases effects of bivalirudin by pharmacodynamic synergism. Use Caution/Monitor. Combination may increase risk of bleeding.

            • collagenase clostridium histolyticum

              bivalirudin increases toxicity of collagenase clostridium histolyticum by anticoagulation. Use Caution/Monitor. Collagenase clostridium histolyticum has high incidence of ecchymosis/contusion at injection site; avoid concomitant anticoagulants (except for low-dose aspirin, ie, up to 150 mg/day).

            • conjugated estrogens, vaginal

              conjugated estrogens, vaginal decreases effects of bivalirudin by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Risk of thromboembolic disorders.

            • cordyceps

              bivalirudin and cordyceps both increase anticoagulation. Modify Therapy/Monitor Closely.

            • cornsilk

              cornsilk decreases effects of bivalirudin by pharmacodynamic antagonism. Use Caution/Monitor. Cornsilk contains vitamin K; consume a consistent amount daily.

            • cortisone

              cortisone, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • cyclophosphamide

              cyclophosphamide increases effects of bivalirudin by unknown mechanism. Use Caution/Monitor. Additive risk of bleeding may be seen in thrombocytopenic patients receiving antineoplastic agents in combination with anticoagulants such as bivalirudin.

            • dabigatran

              bivalirudin and dabigatran both increase anticoagulation. Use Caution/Monitor. Caution is advised, both drugs have the potential to cause bleeding. Concomitant use may increase risk of bleeding.

            • danshen

              bivalirudin and danshen both increase anticoagulation. Use Caution/Monitor.

            • deferasirox

              deferasirox, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Gastric ulceration and GI bleeding have been reported in patients taking deferasirox, use caution when coadministering with other drugs known to increase the risk of peptic ulcers or gastric hemorrhage including anticoagulants.

            • deflazacort

              deflazacort, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • devil's claw

              bivalirudin and devil's claw both increase anticoagulation. Use Caution/Monitor.

            • dexamethasone

              dexamethasone, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • diclofenac

              bivalirudin and diclofenac both increase anticoagulation. Modify Therapy/Monitor Closely.

            • diflunisal

              bivalirudin and diflunisal both increase anticoagulation. Modify Therapy/Monitor Closely.

              diflunisal increases effects of bivalirudin by plasma protein binding competition. Use Caution/Monitor.

            • dong quai

              bivalirudin and dong quai both increase anticoagulation. Modify Therapy/Monitor Closely.

            • epoprostenol

              bivalirudin and epoprostenol both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ethanol

              ethanol increases effects of bivalirudin by unknown mechanism. Use Caution/Monitor. Acute EtOH intoxication.

            • ethotoin

              bivalirudin increases levels of ethotoin by unknown mechanism. Use Caution/Monitor.

              ethotoin, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Hydantoin anticonvulsants increase anticoagulant effects at first, then decrease those effects with continued use (2+ wks). There are multiple mechanisms involved, including enzyme induction, plasma protein binding site competition, and additive effects on prothrombin time.

            • etodolac

              bivalirudin and etodolac both increase anticoagulation. Modify Therapy/Monitor Closely.

            • fenbufen

              bivalirudin and fenbufen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • fennel

              bivalirudin and fennel both increase anticoagulation. Modify Therapy/Monitor Closely.

            • fenoprofen

              bivalirudin and fenoprofen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • feverfew

              bivalirudin and feverfew both increase anticoagulation. Modify Therapy/Monitor Closely.

            • fish oil

              fish oil, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Patients taking fish oil and an anticoagulant or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding. .

            • fish oil triglycerides

              fish oil triglycerides will increase the level or effect of bivalirudin by anticoagulation. Use Caution/Monitor. Prolonged bleeding reported in patients taking antiplatelet agents or anticoagulants and oral omega-3 fatty acids. Periodically monitor bleeding time in patients receiving fish oil triglycerides and concomitant antiplatelet agents or anticoagulants.

            • fludrocortisone

              fludrocortisone, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • fluorouracil

              fluorouracil increases effects of bivalirudin by unspecified interaction mechanism. Use Caution/Monitor. Due to the thrombocytopenic effects of fluorouracil, an additive risk of bleeding may be seen in patients receiving concomitant anticoagulants.

            • flurbiprofen

              bivalirudin and flurbiprofen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • forskolin

              bivalirudin and forskolin both increase anticoagulation. Modify Therapy/Monitor Closely.

            • fosphenytoin

              bivalirudin increases levels of fosphenytoin by unknown mechanism. Use Caution/Monitor.

              fosphenytoin, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Hydantoin anticonvulsants increase anticoagulant effects at first, then decrease those effects with continued use (2+ wks). There are multiple mechanisms involved, including enzyme induction, plasma protein binding site competition, and additive effects on prothrombin time.

            • garlic

              bivalirudin and garlic both increase anticoagulation. Modify Therapy/Monitor Closely.

            • gemcitabine

              gemcitabine increases effects of bivalirudin by unspecified interaction mechanism. Use Caution/Monitor. Due to the thrombocytopenic effects of gemcitabine, an additive risk of bleeding may be seen in patients receiving concomitant anticoagulants.

            • ginger

              bivalirudin and ginger both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ginkgo biloba

              bivalirudin and ginkgo biloba both increase anticoagulation. Modify Therapy/Monitor Closely.

            • glucagon intranasal

              glucagon intranasal increases effects of bivalirudin by unknown mechanism. Use Caution/Monitor.

            • green tea

              green tea, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Combination may increase risk of bleeding, caution is advised.

            • hemin

              bivalirudin, hemin. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Hemin degradation product (ie, hematin) may produce coagulopathy (eg, thrombocytopenia, platelet degranulation) and cause mild anticoagulant effects.

            • horse chestnut seed

              bivalirudin and horse chestnut seed both increase anticoagulation. Modify Therapy/Monitor Closely.

            • hydrocortisone

              hydrocortisone, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • ibrutinib

              ibrutinib will increase the level or effect of bivalirudin by anticoagulation. Use Caution/Monitor. Ibrutinib may increase the risk of hemorrhage in patients receiving antiplatelet or anticoagulant therapies and monitor for signs of bleeding.

            • ibuprofen

              bivalirudin and ibuprofen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ibuprofen IV

              bivalirudin and ibuprofen IV both increase anticoagulation. Modify Therapy/Monitor Closely.

            • icosapent

              icosapent, bivalirudin. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Icosapent may prolong bleeding time; monitor periodically if coadministered with other drugs that affect bleeding.

            • imatinib

              imatinib, bivalirudin. Either increases toxicity of the other by Other (see comment). Modify Therapy/Monitor Closely. Comment: Imatinib may cause thrombocytopenia; bleeding risk increased when imatinib is coadministered with anticoagulants, NSAIDs, platelet inhibitors, and thrombolytic agents; patients requiring anticoagulation while on imatinib should receive LMWH or unfractionated heparin instead of warfarin because of multiple interaction mechanisms of imatinib with warfarin.

            • indomethacin

              bivalirudin and indomethacin both increase anticoagulation. Modify Therapy/Monitor Closely.

            • iodine (radioactive)

              iodine (radioactive) decreases effects of bivalirudin by pharmacodynamic antagonism. Use Caution/Monitor.

            • ketoprofen

              bivalirudin and ketoprofen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ketorolac

              bivalirudin and ketorolac both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ketorolac intranasal

              bivalirudin and ketorolac intranasal both increase anticoagulation. Modify Therapy/Monitor Closely.

            • lofepramine

              lofepramine increases levels of bivalirudin by decreasing metabolism. Use Caution/Monitor.

            • lornoxicam

              bivalirudin and lornoxicam both increase anticoagulation. Modify Therapy/Monitor Closely.

            • meclofenamate

              bivalirudin and meclofenamate both increase anticoagulation. Modify Therapy/Monitor Closely.

            • mefenamic acid

              bivalirudin and mefenamic acid both increase anticoagulation. Modify Therapy/Monitor Closely.

            • melatonin

              melatonin increases effects of bivalirudin by anticoagulation. Use Caution/Monitor. Melatonin may decrease prothrombin time.

            • meloxicam

              bivalirudin and meloxicam both increase anticoagulation. Modify Therapy/Monitor Closely.

            • methimazole

              methimazole decreases effects of bivalirudin by pharmacodynamic antagonism. Use Caution/Monitor.

            • methylprednisolone

              methylprednisolone, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • mistletoe

              bivalirudin increases and mistletoe decreases anticoagulation. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.

            • nabumetone

              bivalirudin and nabumetone both increase anticoagulation. Modify Therapy/Monitor Closely.

            • naproxen

              bivalirudin and naproxen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • nettle

              bivalirudin increases and nettle decreases anticoagulation. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.

            • nintedanib

              nintedanib increases effects of bivalirudin by anticoagulation. Use Caution/Monitor. Nintedanib is a VEGFR inhibitor, and may increase the risk of bleeding; monitor patients on full anticoagulation therapy; monitor closely for bleeding and adjust therapy as needed .

            • omega 3 carboxylic acids

              omega 3 carboxylic acids, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Patients taking omega-3 acids and an anticoagulant or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding.

            • omega 3 fatty acids

              omega 3 fatty acids, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Patients taking omega-3-fatty acids and an anticoagulant or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding. .

            • oxaprozin

              bivalirudin and oxaprozin both increase anticoagulation. Modify Therapy/Monitor Closely.

            • panax ginseng

              bivalirudin and panax ginseng both increase anticoagulation. Modify Therapy/Monitor Closely.

            • parecoxib

              bivalirudin and parecoxib both increase anticoagulation. Modify Therapy/Monitor Closely.

            • pau d'arco

              bivalirudin and pau d'arco both increase anticoagulation. Modify Therapy/Monitor Closely.

            • pegaspargase

              pegaspargase increases effects of bivalirudin by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of bleeding events.

            • phenytoin

              bivalirudin increases levels of phenytoin by unknown mechanism. Use Caution/Monitor.

              phenytoin, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Hydantoin anticonvulsants increase anticoagulant effects at first, then decrease those effects with continued use (2+ wks). There are multiple mechanisms involved, including enzyme induction, plasma protein binding site competition, and additive effects on prothrombin time.

            • phytoestrogens

              bivalirudin and phytoestrogens both increase anticoagulation. Modify Therapy/Monitor Closely.

            • piroxicam

              bivalirudin and piroxicam both increase anticoagulation. Modify Therapy/Monitor Closely.

            • porfimer

              bivalirudin decreases effects of porfimer by pharmacodynamic antagonism. Use Caution/Monitor.

            • prasugrel

              bivalirudin, prasugrel. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Enhanced risk of hemorrhage.

            • prednisolone

              prednisolone, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • prednisone

              prednisone, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • propafenone

              propafenone increases effects of bivalirudin by decreasing metabolism. Use Caution/Monitor.

            • propylthiouracil

              propylthiouracil decreases effects of bivalirudin by pharmacodynamic antagonism. Use Caution/Monitor.

            • reishi

              bivalirudin and reishi both increase anticoagulation. Modify Therapy/Monitor Closely.

            • reteplase

              bivalirudin and reteplase both increase anticoagulation. Modify Therapy/Monitor Closely.

            • rifabutin

              rifabutin decreases levels of bivalirudin by increasing metabolism. Use Caution/Monitor.

            • rivaroxaban

              rivaroxaban, bivalirudin. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Avoid concurrent use of rivaroxaban with other anticoagulants due to increased bleeding risk other than during therapeutic transition periods where patients should be observed closely. Monitor for signs/symptoms of blood loss.

            • salicylates (non-asa)

              bivalirudin and salicylates (non-asa) both increase anticoagulation. Modify Therapy/Monitor Closely.

            • salsalate

              bivalirudin and salsalate both increase anticoagulation. Modify Therapy/Monitor Closely.

            • saw palmetto

              saw palmetto increases toxicity of bivalirudin by unspecified interaction mechanism. Use Caution/Monitor. May increase risk of bleeding.

            • Siberian ginseng

              bivalirudin and Siberian ginseng both increase anticoagulation. Modify Therapy/Monitor Closely.

            • sulfasalazine

              bivalirudin and sulfasalazine both increase anticoagulation. Modify Therapy/Monitor Closely.

            • sulindac

              bivalirudin and sulindac both increase anticoagulation. Modify Therapy/Monitor Closely.

            • tenecteplase

              bivalirudin and tenecteplase both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ticagrelor

              ticagrelor, bivalirudin. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Increased risk of bleeding during concomitant use of medications that increase potential for bleeding.

            • tipranavir

              tipranavir increases effects of bivalirudin by pharmacodynamic synergism. Use Caution/Monitor. Tipranavir has mild antiplatelet activity that may incr bleeding risk.

            • tolfenamic acid

              bivalirudin and tolfenamic acid both increase anticoagulation. Modify Therapy/Monitor Closely.

            • tolmetin

              bivalirudin and tolmetin both increase anticoagulation. Modify Therapy/Monitor Closely.

            • triamcinolone acetonide injectable suspension

              triamcinolone acetonide injectable suspension, bivalirudin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • triclofos

              triclofos increases effects of bivalirudin by unspecified interaction mechanism. Use Caution/Monitor.

            • vorapaxar

              bivalirudin, vorapaxar. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Coadministration of anticoagulants, antiplatelets, or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding.

            • vortioxetine

              vortioxetine and bivalirudin both increase anticoagulation. Use Caution/Monitor.

            • zanubrutinib

              bivalirudin, zanubrutinib. Either increases effects of the other by anticoagulation. Modify Therapy/Monitor Closely. Zanubrutinib-induced cytopenias increases risk of hemorrhage. Coadministration of zanubritinib with antiplatelets or anticoagulants may further increase this risk.

            Minor (17)

            • acetaminophen

              acetaminophen increases effects of bivalirudin by unknown mechanism. Minor/Significance Unknown.

            • acetaminophen IV

              acetaminophen IV increases effects of bivalirudin by unknown mechanism. Minor/Significance Unknown.

            • acetaminophen rectal

              acetaminophen rectal increases effects of bivalirudin by unknown mechanism. Minor/Significance Unknown.

            • alprostadil intracavernous/urethral

              alprostadil intracavernous/urethral increases effects of bivalirudin by pharmacodynamic synergism. Minor/Significance Unknown.

            • ceftaroline

              ceftaroline increases effects of bivalirudin by Other (see comment). Minor/Significance Unknown. Comment: Cephalosporins with a methylthiotetrazole (MTT) side ring (eg, cefotetan, cefoperazone) are more frequently associated with hypoprothrombinemic activity.

            • chlorella

              chlorella decreases effects of bivalirudin by pharmacodynamic antagonism. Minor/Significance Unknown. Theoretical, due to vitamin K content.

            • demeclocycline

              demeclocycline increases effects of bivalirudin by pharmacodynamic synergism. Minor/Significance Unknown.

            • dexmethylphenidate

              dexmethylphenidate increases effects of bivalirudin by decreasing metabolism. Minor/Significance Unknown.

            • doxycycline

              doxycycline increases effects of bivalirudin by pharmacodynamic synergism. Minor/Significance Unknown.

            • glyburide

              glyburide increases effects of bivalirudin by unspecified interaction mechanism. Minor/Significance Unknown.

            • mineral oil

              mineral oil decreases levels of bivalirudin by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

            • minocycline

              minocycline increases effects of bivalirudin by pharmacodynamic synergism. Minor/Significance Unknown.

            • oxytetracycline

              oxytetracycline increases effects of bivalirudin by pharmacodynamic synergism. Minor/Significance Unknown.

            • quinidine

              quinidine increases effects of bivalirudin by decreasing metabolism. Minor/Significance Unknown.

            • tetracycline

              tetracycline increases effects of bivalirudin by pharmacodynamic synergism. Minor/Significance Unknown.

            • verteporfin

              bivalirudin decreases effects of verteporfin by pharmacodynamic antagonism. Minor/Significance Unknown.

            • vitamin E

              vitamin E, bivalirudin. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Vitamin E at RDA does not change INR in pts. on chronic warfarin therapy; megadoses (~10x RDA) may enhance anticoagulant effects in vitamin K deficient pts.

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            Adverse Effects

            >10%

            Back pain (42%)

            General pain (15%)

            Nausea (15%)

            Hemorrhage, minor (13.6%)

            Headache (12%)

            Hypotension (12%)

            1-10%

            Injection site pain (8%)

            Insomnia (7%)

            Pelvic pain (6%)

            Hypertension (6%)

            Anxiety (6%)

            Vomiting (6%)

            Bradycardia (5%)

            Dyspepsia (5%)

            Abdominal pain (5%)

            Fever (5%)

            Nervousness (5%)

            Urinary retention (4%)

            Hemorrhage, major (2.3%)

            ≥3g/dL fall in Hgb (1.9%)

            TIMI minor bleeding (1.3%)

            RBC transfusions (1.3%)

            Postmarketing Reports

            Pulmonary hemorrhage

            Cardiac tamponade

            INR increased

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            Warnings

            Contraindications

            Active major bleeding

            Hypersensitivity

            Cautions

            Bleeding may occur

            Use caution in renal impairment

            Not for IM administration

            Intended for use with aspirin

            Hemorrhage may occur at any site; discontinue bivalirudin if unexplained fall in blood pressure or hematocrit occurs

            Monitor for signs and symptoms of bleeding; monitor more frequently for bleeding, patients with disease states associated with increased risk of bleeding

            An increased risk of thrombus formation, including fatal outcomes, reported with use of bivalirudin in gamma brachytherapy; if decision made to use bivalirudin during brachytherapy procedures, maintain meticulous catheter technique, with frequent aspiration and flushing, paying special attention to minimizing conditions of stasis within catheter or vessels

            Bivalirudin affects international normalized ratio (INR); INR measurements made in patients treated with bivalirudin may not be useful for determining appropriate dose of warfarin

            Acute stent thrombosis (<4 hr) reported at a greater frequency with bivalirudin compared to heparin treated patients; patients should remain for at least 24 hr in a facility capable of managing ischemic complications and should be carefully monitored following primary PCI for signs and symptoms consistent with myocardial ischemia

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            Pregnancy & Lactation

            Pregnancy

            There are no data available in pregnant women to inform a drug-associated risk of adverse developmental outcomes

            Animal data

            • Reproduction studies in rats and rabbits administered subcutaneously doses up to 1.6 times and 3.2 times maximum recommended human dose (MRHD) of 15 mg/kg/day based on body surface area (BSA) during organogenesis, respectively, revealed no evidence of fetal harm

            Lactation

            Not known whether drug is present in human milk; no data are available on effects on breastfed child or on milk production; developmental and health benefits of breastfeeding should be considered along with clinical need for therapy and any potential adverse effects on breastfed child from therapy or from underlying maternal condition

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Competitive, direct thrombin inhibitor; thrombin enables fibrinogen conversion to fibrin during the coagulation cascade; Inhibition of fibrinogen conversion to fibrin inhibits thrombus development

            Inhibits both free and clot-bound thrombin and thrombin-induced platelet aggregation

            Synthetic analog of hirudin

            Pharmacokinetics

            Half-Life: 25 min (normal renal function); 57 min (severe renal impairment)

            Duration: ~ 1 hr after infusion discontinued

            Protein Bound: Minimal

            Clearance: 60-89 mL/min; Reduced in severe renal impairment

            Metabolism: Blood proteases

            Excretion: renal

            Dialyzable: Yes

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            Administration

            IV Incompatibilities

            No incompatibilities observed with glass bottles or polyvinyl chloride bags & administration sets

            Y-site: alteplase, amiodarone, amphotericin B, chlorpromazine, diazepam, dobutamine (concentrations 4mg/mL or greater), prochlorperazine, reteplase, streptokinase, vancomycin

            IV Compatibilities

            Solution: D5W, NS

            Y-site: abciximab, alfentanil, ampicillin, ampicillin/sulbactam, azithromycin, ciprofloxacin, diphenhydramine, dobutamine (compatible at concentrations up to 4mg/mL; incompatible at 12.5mg/mL), dopamine, epinephrine, fentanyl, furosemide, heparin, lidocaine, lorazepam, MgSO4, midazolam, morphine SO4, KCl, NaHCO3, TMP-SMX, warfarin, most cephalosporins

            IV Preparation

            To each 250 mg vial add 5 mL SWI

            Gently swirl until all material is dissolved

            Dilute each vial in 50 mL of D5W or NS to yield a final concentration of 5 mg/mL

            If low-rate infusion is used after initial infusion, a lower concentration bag should be prepared

            Inspect for particulate matter and discoloration prior to administration

            Do not use preparations containing particulate matter

            Reconstituted drug will be a clear to slightly opalescent, colorless to slightly yellow solution

            IV Administration

            Initial bolus injection followed by continuous infusion

            Storage

            Store bivalirudin dosage units at 20-25°C (68-77°F); excursions of 15-30°C permitted

            Do not freeze reconstituted or diluted bivalirudin

            Reconstituted material may be stored at 2-8°C up to 24 hours

            Diluted bivalirudin with a concentration between 0.5mg/mL and 5mg/mL is stable at room temperature for up to 24 hours

            Discard any unused portion of reconstituted solution remaining in vial

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            Images

            BRAND FORM. UNIT PRICE PILL IMAGE
            bivalirudin intravenous
            -
            250 mg vial
            bivalirudin intravenous
            -
            250 mg vial
            bivalirudin intravenous
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            250 mg vial
            bivalirudin intravenous
            -
            250 mg vial
            bivalirudin intravenous
            -
            250 mg vial
            bivalirudin intravenous
            -
            250 mg vial
            bivalirudin intravenous
            -
            250 mg vial
            bivalirudin intravenous
            -
            250 mg vial
            bivalirudin intravenous
            -
            250 mg vial
            Angiomax intravenous
            -
            250 mg vial

            Copyright © 2010 First DataBank, Inc.

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            Patient Handout

            Patient Education
            bivalirudin intravenous

            NO MONOGRAPH AVAILABLE AT THIS TIME

            USES: Consult your pharmacist.

            HOW TO USE: Consult your pharmacist.

            SIDE EFFECTS: Consult your pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

            PRECAUTIONS: Consult your pharmacist.

            DRUG INTERACTIONS: Consult your pharmacist.Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

            OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.

            NOTES: No monograph available at this time.

            MISSED DOSE: Consult your pharmacist.

            STORAGE: Consult your pharmacist.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

            Information last revised July 2016. Copyright(c) 2021 First Databank, Inc.

            IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

            To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

            Adding plans allows you to:

            • View the formulary and any restrictions for each plan.
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            • Compare formulary status to other drugs in the same class.
            • Access your plan list on any device – mobile or desktop.

            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.