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Bivalirudin (Hirulog)
( by-val-ih- ROO-din)
Pregnancy Category: Hirulog (Rx)

Classification: Anticoagulant

See Also: See also Anticoagulants.

Action/Kinetics: Direct-acting thrombin inhibitor. Can inactivate both soluble and clot-bound thrombin. Binding to thrombin is reversible and occurs in a 1:1 relationship. When bound to thrombin, all effects of thrombin are inhibited, including activation of platelets, cleavage of fibrinogen, and activation of the positive amplification reactions of thrombin. Advantages over heparin include activity against clot-bound thrombin, more predictable anticoagulation, and no inhibition by components of the platelet release reaction. Onset after IV bolus during cardiac catheterization: 2 min ; peak response: 15 min; duration: 2 hr. Peak plasma levels, after SC: 2 hr. t 1/2, after IV: Less than 1 hr. Metabolized in the liver with about 20% excreted unchanged in the urine.

Uses: IV: Adjunct to streptokinase in acute MI. To reduce ischemic complications in postinfarction MI clients undergoing coronary angioplasty. Unstable angina. SC: Prevent DVT in orthopedic surgery.

Contraindications: Use in cerebral aneurysm, intracranial hemorrhage, or general uncontrollable hemorrhage.

Special Concerns: Dose may have to be reduced in impaired renal function. Increased risk of hemorrhage with GI ulceration or hepatic disease. Hypertension may increase risk of cerebral hemorrhage. Use with caution following recent surgery or trauma and during lactation.

Side Effects: Major side effect is bleeding with possiblity (infrequent) of major hemorrhage, including intracranial hemorrhage and retroperitoneal hemorrhage. GI: N&V, abdominal cramps, diarrhea. CNS: Headache. Dermatologic: Hematoma at IV infusion site, pain at SC injection site.

Laboratory Test Alterations: Prolongation of APTT, activated clotting time, thrombin time, and PT.

?IV MI clients undergoing coronary angioplasty.
Initial bolus: 1 mg/kg; then 2.5 mg/kg/hr for 4 hr by continuous IV infusion followed by 0.2 mg/kg/hr for 14-20 hr. Initiate immediately before angioplasty. Also give aspirin 300-325 mg.
Unstable angina.
0.2 mg/kg/hr by continuous IV infusion for up to 5 days. Use in addition to aspirin, nitrates, or calcium channel blockers.
Adjunct to streptokinase in acute MI.
0.5 mg/kg/hr by IV infusion decreasing to 0.1 mg/kg/hr after 12 hr. Start infusion immediately before or with streptokinase, 1.5 million units IV over 45 -60 min. Continue infusion until 1 hr before second angiogram (average of 4.7 days). Aspirin, 325 mg, is given before bivalirudin/streptokinase.
?SC Prophylaxis of DVT in orthopedic surgery.
1 mg/kg q 8 hr for up to 14 days.

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