Angiomax

Generic Name: Bivalirudin
Class: Direct Thrombin Inhibitors
Chemical Name: d - Phenylalanyl - l - prolyl - l - arginyl - l - prolylglycylglycylglycylglycyl - l - asparaginylglycyl - l - α - aspartyl - l - phenylalanyl - l - α - glutamyl - l - α - glutamyl - l - isoleucyl - l - prolyl - l - α - glutamyl - l - α - glutamyl - l - tyrosyl - l - leucine
CAS Number: 128270-60-0

Special Alerts:

The Editors of AHFS Drug Information (AHFS DI) and AHFS DI Essentials wish to inform you of an error in the monographs for bivalirudin 20:12.04.12 that resulted from an error in one of the cited references, the American College of Chest Physicians (ACCP) guideline on treatment and prevention of heparin-induced thrombocytopenia (Warkentin TE, Greinacher A, Koster A et al. Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed). Chest. 2008; 133 (Suppl):340S-80S).^{10 25}

The error appears under the subhead Heparin-induced Thrombocytopenia in Patients Undergoing Cardiac Surgery, in Dosage and Administration. In the second sentence under this subhead, the statement should read:

“During cardiopulmonary bypass, initially, 1 mg/kg by direct IV injection followed by 2.5 mg/kg per hour by continuous IV infusion has been used;^{10 24} if needed, additional direct IV doses of 0.1–0.5 mg/kg have been given to maintain a 2.5-fold or greater prolongation of the baseline ACT.²⁴ ”

The originally stated dosage of 0.1–0.5 mg for additional direct IV doses of bivalirudin is incorrect.²⁵

The following reflects the corrected version of this information, incorporating the change noted above.

Introduction

Anticoagulant; synthetic peptide analog of hirudin, an anticoagulant polypeptide found in the saliva of the medicinal leech (Hirudo medicinalis).^{1 2 3 4 5 6}

Uses for Angiomax

Acute Ischemic Complications of Percutaneous Coronary Intervention

Used with aspirin to reduce the risk of acute ischemic complications (e.g., death, MI, need for urgent revascularization procedures) in patients with unstable angina or non-ST-segment-elevation MI (i.e., non-ST-segment-elevation acute coronary syndromes) undergoing PCI, including percutaneous transluminal coronary angioplasty (PTCA).^{1 8 9 11 15 17}

American College of Chest Physicians (ACCP) recommends anticoagulant therapy (e.g., heparin, low molecular weight heparin, bivalirudin, fondaparinux) for all patients presenting with non-ST-segment-elevation acute coronary syndromes.¹⁷ ACCP suggests the use of bivalirudin in combination with clopidogrel over heparin for initial antithrombotic therapy in patients at moderate to high risk for an ischemic event and who are scheduled for very early coronary angiography (within <6 hours).¹⁷

Efficacy in patients with non-ST-segment-elevation acute coronary syndromes undergoing PCI similar to that of high-dose heparin.^{1 5}

Used with aspirin and “provisional” treatment with a GP IIb/IIIa-receptor inhibitor in selected patients undergoing PCI who have complications (i.e., prolonged ischemia, decreased perfusion [TIMI grade 0–2 flow] or slow reflow, dissection with decreased perfusion, new or suspected thrombus, persistent residual stenosis, distal embolism, unplanned or suboptimal stenting, side branch closure, abrupt closure, or other clinical instability).^{1 8 11 14 17} Efficacy in such patients similar to that of heparin and routine treatment with a GP IIb/IIIa-receptor inhibitor.^{1 8 9 11 14 16 17}

ACC, AHA, and the Society for Cardiovascular Angiography and Interventions (SCAI) suggest bivalirudin as an alternative to heparin and a GP IIb/IIIa-receptor inhibitor in patients undergoing PCI who are at low risk for ischemic complications.¹⁵

ACCP recommends either bivalirudin and provisional treatment with a GP IIb/IIIa-receptor inhibitor or heparin and routine treatment with a GP IIb/IIIa-receptor inhibitor in patients with non-ST-segment-elevation acute coronary syndromes undergoing PCI who are at low to moderate risk for ischemic complications.¹⁷

Safety and efficacy not established in patients with acute coronary syndromes who are not undergoing PTCA or PCI.¹

Heparin-induced Thrombocytopenia in Patients Undergoing PCI

Used with aspirin in patients undergoing PCI who have, or are at risk for, heparin-induced thrombocytopenia (HIT).^{1 10 15}

ACC/AHA/SCAI recommend bivalirudin or argatroban and ACCP recommends bivalirudin, argatroban, or lepirudin as a substitute for unfractionated heparin or low molecular weight heparin in patients with HIT undergoing PCI.^{10 15}

ACCP suggests use of a nonheparin anticoagulant over continued therapy with unfractionated or low molecular weight heparin in patients with a history of HIT (antibody negative) who require cardiac catheterization or PCI.¹⁰

Heparin-induced Thrombocytopenia in Patients Undergoing Cardiac Surgery

Recommended as a substitute for heparin in patients with acute HIT (thrombocytopenic and HIT-antibody positive) who require cardiac surgery† (e.g., coronary artery bypass grafting [CABG]).^{10 24} ACCP recommends delaying surgery (if possible) until HIT antibodies are no longer detected or use of bivalirudin for intraoperative anticoagulation during cardiopulmonary bypass or “off-pump” cardiac surgery, provided special precautions to prevent blood stasis are followed.^{10 24 26} (See Patients with HIT Undergoing Cardiac Surgery under Cautions.)

Acute ST-Segment-Elevation MI

Used as an alternative to heparin in patients with acute ST-segment-elevation MI†.^{20 21 22} May be used in patients who have been pretreated with heparin and who are to undergo PCI; may also be used as an alternative to heparin in patients who have received fondaparinux in conjunction with a thrombolytic agent prior to PCI.²⁰

Angiomax Dosage and Administration

General

• 
  

  Manufacturer states that bivalirudin is intended for use concomitantly with aspirin 300–325 mg daily.¹ However, ACC/AHA/SCAI and ACCP recommend lower maintenance dosages of aspirin (e.g., 75–162 mg daily).^{15 17 18 19 20 21 23}

  
  

Administration

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer by direct IV injection followed by IV infusion.¹ Do not administer IM.¹

Reconstitution

Reconstitute vial containing 250 mg of lyophilized bivalirudin with 5 mL of sterile water for injection (swirl gently) to provide a solution containing 50 mg/mL.¹

Discard any unused reconstituted solution.¹

Dilution

Dilute reconstituted solution in 50 mL of 5% dextrose or 0.9% sodium chloride injection to a final concentration of 5 mg/mL for direct IV injection and infusion.¹

For low-rate infusion, further dilute the 5-mg/mL solution in 500 mL of 5% dextrose or 0.9% sodium chloride injection to a final concentration of 0.5 mg/mL.^{1 7}

Dosage

Adults

Acute Ischemic Complications of PCI

IV

0.75 mg/kg (5-mg/mL solution) by direct IV injection immediately before PCI, followed by 1.75 mg/kg per hour (5-mg/mL solution) by continuous IV infusion for the duration of the procedure.¹ Obtain an activated clotting time (ACT) (as measured by a Hemochron device) 5 minutes after initial loading dose and administer an additional direct IV dose of 0.3 mg/kg if needed (e.g., if the ACT is <225 seconds).^{1 8}

May continue infusion for up to 4 hours after the procedure if necessary.¹ If needed, administer an additional IV infusion (0.5-mg/mL solution) at 0.2 mg/kg per hour for up to 20 hours.¹

Heparin-induced Thrombocytopenia in Patients Undergoing PCI

IV

0.75 mg/kg (5-mg/mL solution) by direct IV injection immediately before PCI, followed by 1.75 mg/kg per hour (5-mg/mL solution) by continuous IV infusion for the duration of the procedure.¹

May continue infusion for up to 4 hours after the procedure if necessary.¹ If needed, administer an additional IV infusion (0.5-mg/mL solution) at 0.2 mg/kg per hour for up to 20 hours.¹

Heparin-induced Thrombocytopenia in Patients Undergoing Cardiac Surgery†

IV

During “off-pump” cardiac surgery (i.e., without cardiopulmonary bypass), 0.75 mg/kg by direct IV injection, followed by 1.75 mg/kg per hour by continuous IV infusion to maintain an ACT >300 seconds has been used.^{10 26}

During cardiopulmonary bypass, initially, 1 mg/kg by direct IV injection followed by 2.5 mg/kg per hour by continuous IV infusion has been used;^{10 24} if needed, additional direct IV doses of 0.1–0.5 mg/kg have been given to maintain a 2.5-fold or greater prolongation of the baseline ACT.²⁴ In addition, 50 mg of bivalirudin is added to the recirculating priming fluid of the cardiopulmonary bypass circuit.^{10 24}

Acute ST-Segment-Elevation MI†

IV

0.25 mg/kg by direct IV injection followed by 0.5 mg/kg per hour by continuous IV infusion for the first 12 hours, then 0.25 mg/kg per hour for the subsequent 36 hours, has been used.^{21 22} Obtain aPTT 12 and 24 hours after the initial dosage; adjust dosage if needed.²¹

Special Populations

Renal Impairment

Reduction of the initial loading dose not necessary in patients with moderate to severe renal impairment.^{1 7} Closely monitor activated clotting time (ACT) in patients with renal impairment.¹ Reduce infusion rate to 1 mg/kg per hour in patients with severe renal impairment (Cl_cr <30 mL/minute).¹ In dialysis-dependent patients, reduce off-dialysis infusion rate to 0.25 mg/kg per hour.¹

Cautions for Angiomax

Contraindications

• 
  

  Active major bleeding.¹

  
  


• 
  

  Known hypersensitivity to bivalirudin or any ingredient in the formulation.¹

  
  

Warnings/Precautions

Warnings

Hematologic Effects

Possible bleeding, especially at site of arterial puncture.^{1 7} Unexplained decreases in hematocrit, hemoglobin, or BP may indicate hemorrhage.¹

Discontinue if severe hemorrhage occurs.¹ Use with caution in patients with an increased risk of hemorrhage.^{1 7}

Increased risk of potentially fatal thrombosis during vascular brachytherapy procedures; use caution.¹ Assess catheter function frequently by attempting to aspirate blood, and ensure patency by repeated flushing.¹ Minimize conditions promoting stasis within the catheter or circulatory system.^{1 10}

Sensitivity Reactions

Hypersensitivity

Positive bivalirudin antibody tests found rarely in clinical studies; however, no allergic or anaphylactic reactions reported.^{1 7}

General Precautions

Factors Increasing Risk of Hemorrhage

Increased risk of major bleeding events with concomitant heparin, warfarin, thrombolytic, or GP IIb/IIIa-receptor inhibitor therapy in clinical trials.¹ (See Common Adverse Effects and see Specific Drugs under Interactions.) No experience with concomitant administration of plasma expanders such as dextran.¹

Use with caution in patients with disease states associated with increased risk of hemorrhage.¹

Brachytherapy Procedures

Use with caution during vascular brachytherapy procedures because of an increased risk of potentially fatal thrombosis.¹

Patients with HIT Undergoing Cardiac Surgery

Possible formation of clots due to degradation of bivalirudin in areas of blood stasis; special maneuvers needed to avoid stasis within the cardiopulmonary bypass circuit during and after cardiac surgery.^{10 24 26} Avoid use of cardiotomy suction; also avoid use of patient blood to test graft patency or for cardioplegia solutions.^{10 24 26}

Specific Populations

Pregnancy

Category B.¹

Lactation

Not known whether bivalirudin is distributed into milk.¹ Use with caution.¹

Pediatric Use

Safety and efficacy not established in pediatric patients.¹

Geriatric Use

No substantial differences in safety or efficacy relative to younger adults.^{1 7}

Renal Impairment

Dosage reduction recommended in patients with moderate to severe renal impairment.¹ (See Renal Impairment under Dosage and Administration.)

Common Adverse Effects

Major hemorrhagic events less frequent with bivalirudin with or without provisional GP IIb/IIIa-receptor inhibitor therapy (2.3%) compared with unfractionated heparin and routine GP IIb/IIIa-receptor inhibitor therapy (4%).¹

Nonhemorrhagic effects in patients with unstable angina undergoing PTCA: Back pain,¹ pain (unspecified),¹ nausea,¹ headache,¹ hypotension,¹ injection site pain,¹ insomnia,¹ hypertension,¹ vomiting,¹ pelvic pain,¹ anxiety,¹ bradycardia,¹ dyspepsia,¹ abdominal pain,¹ fever,¹ nervousness,¹ urinary retention.¹

Nonhemorrhagic effects in patients undergoing PCI and receiving provisional therapy with a GP IIb/IIIa-receptor inhibitor: Back pain, angina pectoris,¹ pain (unspecified),¹ hypotension,¹ nausea,¹ injection site pain,¹ headache,¹ chest pain.¹

Interactions for Angiomax

Specific Drugs

Drug	Interaction	Comments
Aspirin	Increased risk of hemorrhage13
GP IIb/IIIa-receptor inhibitors	Increased risk of hemorrhage1
Heparin	Increased risk of hemorrhage1
Heparin, low molecular weight	No apparent pharmacodynamic interaction13	Limited data; safety and efficacy of combination therapy not established13
Plasma-volume expanders (e.g., dextran)	No experience with concomitant therapy1
Thrombolytic agents	Increased risk of hemorrhage1
Ticlopidine	No apparent pharmacodynamic interaction13	Limited data; safety and efficacy of combination therapy not established13
Warfarin	Increased risk of hemorrhage1

Angiomax Pharmacokinetics

Absorption

Onset

Immediate anticoagulant effect.¹

Duration

Effects are dose- and concentration-dependent and reversible; thrombin slowly cleaves the bivalirudin-Arg₃-Pro₄ bond, which results in recovery of the thrombin active site function.^{1 3 4} Coagulation times return to normal approximately 1–2 hours after cessation of infusion.^{1 7}

Distribution

Extent

Not known whether the drug is distributed into human milk.¹

Plasma Protein Binding

Does not bind to plasma proteins (other than thrombin).¹

Elimination

Metabolism

Cleared from the plasma by a combination of renal mechanisms and intracellular proteolysis.^{1 b}

Elimination Route

Approximately 20% of unchanged bivalirudin is cleared renally, and the remainder presumably undergoes intracellular proteolysis.^b

Half-life

22 minutes.¹

Special Populations

In patients with mild renal impairment (GFR of 60–89 mL/minute), half-life is 25 minutes.¹

In patients with moderate renal impairment (GFR of 30–59 mL/minute), half-life is 34 minutes.¹

In patients with severe renal impairment (GFR of 10–29 mL/minute), half-life is 57 minutes.¹

In dialysis-dependent patients, off-dialysis half-life is 3.5 hours.¹

Total body clearance reduced by about 20% in patients with moderate to severe renal impairment and by 80% in dialysis-dependent patients.¹

Approximately 25% of drug removed by hemodialysis.¹

Stability

Storage

Parenteral

Powder for Injection

20–25°C (may be exposed to 15–30°C).¹

Reconstituted solution (50 mg/mL) may be stored at 2–8°C for up to 24 hours.¹

Diluted IV solutions (0.5–5 mg/mL) are stable at room temperature for up to 24 hours.¹

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution Compatibility¹

Compatible
Dextrose 5% in water
Sodium chloride 0.9%

Drug Compatibility^HID

Y-Site CompatibilityHID

Compatible
Abciximab
Alfentanil HCl
Amikacin sulfate
Aminophylline
Ampicillin sodium
Ampicillin sodium-sulbactam sodium
Azithromycin
Aztreonam
Bretylium tosylate
Bumetanide
Butorphanol tartrate
Calcium gluconate
Cefazolin sodium
Cefepime HCl
Cefotaxime sodium
Cefoxitin sodium
Ceftazidime
Ceftizoxime sodium
Ceftriaxone sodium
Cefuroxime sodium
Cimetidine HCl
Ciprofloxacin
Clindamycin phosphate
Co-trimoxazole
Dexamethasone sodium phosphate
Digoxin
Diltiazem HCl
Diphenhydramine HCl
Dobutamine HCl
Dopamine HCl
Doxycycline hyclate
Droperidol
Enalaprilat
Ephedrine sulfate
Epinephrine HCl
Epoprostenol sodium
Eptifibatide
Erythromycin lactobionate
Esmolol HCl
Famotidine
Fentanyl citrate
Fluconazole
Furosemide
Gentamicin sulfate
Haloperidol lactate
Heparin sodium
Hydrocortisone sodium succinate
Hydromorphone HCl
Isoproterenol HCl
Labetalol HCl
Levofloxacin
Lidocaine HCl
Lorazepam
Magnesium sulfate
Mannitol
Meperidine HCl
Methylprednisolone sodium succinate
Metoclopramide HCl
Metronidazole
Midazolam HCl
Milrinone lactate
Morphine sulfate
Nalbuphine HCl
Nitroglycerin
Norepinephrine bitartrate
Phenylephrine HCl
Piperacillin sodium-tazobactam
Potassium chloride
Procainamide HCl
Promethazine HCL
Ranitidine HCl
Sodium bicarbonate
Sodium nitroprusside
Sufentanil citrate
Theophylline
Thiopental sodium
Ticarcillin disodium-clavulanate potassium
Tirofiban HCl
Tobramycin sulfate
Verapamil HCl
Warfarin sodium
Incompatible
Alteplase
Amiodarone HCl
Amphotericin B
Chlorpromazine HCl
Diazepam
Prochlorperazine edisylate
Reteplase
Vancomycin HCl

ActionsActions

• 
  

  Specific and reversible direct thrombin inhibitor that binds to circulating and clot-bound thrombin.^{1 2 3 4}

  
  


• 
  

  Inhibition of thrombin prevents various steps in the coagulation process (e.g., activation of factors V, VIII, and XIII; conversion of fibrinogen to fibrin; platelet activation and aggregation).^{1 2 3 4}

  
  


• 
  

  Prolongs activated clotting time (ACT), aPTT, thrombin time (TT), and PT.^{1 7}

  
  

Advice to Patients

• 
  

  Importance of patients reporting any signs of bleeding (e.g., bruising, petechiae, hematuria) to clinicians immediately.¹

  
  


• 
  

  Importance of patients informing clinicians of history of bleeding disorders or impaired renal function.¹

  
  


• 
  

  Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.¹

  
  


• 
  

  Importance of patients informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs as well as any concomitant diseases.¹

  
  


• 
  

  Importance of informing patients of other important precautionary information.¹ (See Cautions.)

  
  

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Bivalirudin

Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Parenteral	For injection, for IV infusion	250 mg	Angiomax	Medicines Company

Disclaimer

This report on medications is for your information only, and is not considered individual patient advice. Because of the changing nature of drug information, please consult your physician or pharmacist about specific clinical use.

The American Society of Health-System Pharmacists, Inc. and Drugs.com represent that the information provided hereunder was formulated with a reasonable standard of care, and in conformity with professional standards in the field. The American Society of Health-System Pharmacists, Inc. and Drugs.com make no representations or warranties, express or implied, including, but not limited to, any implied warranty of merchantability and/or fitness for a particular purpose, with respect to such information and specifically disclaims all such warranties. Users are advised that decisions regarding drug therapy are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and the information is provided for informational purposes only. The entire monograph for a drug should be reviewed for a thorough understanding of the drug's actions, uses and side effects. The American Society of Health-System Pharmacists, Inc. and Drugs.com do not endorse or recommend the use of any drug. The information is not a substitute for medical care.

AHFS Drug Information. © Copyright, 1959-2011, Selected Revisions March 25, 2011. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

1. The Medicines Company. Angiomax (bivalirudin) for injection prescribing information. Cambridge, MA; 2005 Dec 6.

2. Haines ST, Bussey HI. Thrombosis and the pharmacology of antithrombotic agents. Ann Pharmacother. 1995; 29:892-905. [IDIS 353388] [PubMed 8547739]

3. Stringer KA, Lindenfeld J. Hirudins: antithrombin anticoagulants. Ann Pharmacother. 1992; 26:1535-40. [IDIS 306624] [PubMed 1482812]

4. Bates SM, Weitz JI. Direct thrombin inhibitors for treatment of arterial thrombosis: potential differences between bivalirudin and hirudin. Am J Cardiol. 1998; 82:12-8P.

5. Bittl JA, Strony J, Brinker JA et al for the Hirulog Angioplasty Study investigators. Treatment with bivalirudin (hirulog) as compared with heparin during coronary angioplasty for unstable or postinfarction angina. N Engl J Med. 1995; 333:764-9. [IDIS 353197] [PubMed 7643883]

6. Bittl JA, Feit F for Hirulog Angioplasty Study investigators. A randomized comparison of bivalirudin and heparin in patients undergoing coronary angioplasty for postinfarction angina. Am J Cardiol. 1998; 82:43-9P. [PubMed 9671007]

7. The Medicines Company, Cambridge, MA: Personal communication.

8. Lincoff AM, Bittl JA, Harrington RA et al. Bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and planned glycoprotein IIb/IIIa blockade during percutaneous coronary intervention: REPLACE-2 randomized trial. JAMA. 2003; 289:853-63. [IDIS 493155] [PubMed 12588269]

9. Saw J, Lincoff M, DeSmet W et al. Lack of clopidogrel pretreatment effect on the relative efficacy of bivalirudin with provisional glycoprotein IIb/IIIa blockade compared to heparin with routine glycoprotein IIb/IIIa blockade: a REPLACE-2 substudy. J Am Coll Cardiol. 2004; 44:1194-9. [IDIS 524399] [PubMed 15364319]

10. Warkentin TE, Greinacher A, Koster A et al. Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians evidenced-based clinical practice guidelines (8th ed) Chest. 2008; 133 (Suppl):340S-80S

11. Popma JJ, Berger P, Ohman EM et al. Antithrombotic therapy in patients undergoing percutaneous coronary intervention. Chest. 2001; 119(Suppl):321S-36S.

12. Harrington RA, Becker RC, Ezekowitz M et al. Antithrombotic therapy in coronary artery disease. Chest. 2004; 126:513S-48S. [IDIS 523845] [PubMed 15383483]

13. The Medicines Company. Angiomax (bivalirudin) for injection prescribing information. Cambridge, MA; 2002 Jun 18.

14. Lincoff, AM, Kleiman NS, Kereiakes DJ et al. Long-term efficacy of bivalirudin and provisional glycoprotein IIb/IIIa blockade vs heparin and planned glycoprotein IIb/IIIa blockade during percutaneous coronary revascularization: REPLACE-2 randomized trial. JAMA. 2004; 292:696-703.

15. Smith SC, Feldman TE, Hirschfeld JW et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Revise the 2001 Guidelines for Percutaneous Coronary Intervention). 2005. Available at the American College of Cardiology web site.

16. Lansky AJ, Hochman JS, Ward PA et al. Percutaneous coronary intervention and adjunctive pharmacotherapy in women: a statement for healthcare professionals from the American Heart Association. Circulation. 2005; 111:940-5. [PubMed 15687113]

17. Harrington RA, Becker RC, Cannon CP et al. Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes.American College of Chest Physicians evidenced-based clinical practice guidelines (8th ed). Chest. 2008; 133:670S-707S. [PubMed 18574276]

18. King SB, Smith SC, Hirshfeld JW et al. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008; 51:172-9. [PubMed 18191745]

19. Becker RC, Meade TW, Berger PB et al. The primary and secondary prevention of coronary artery disease: American College of Chest Physicians evidenced-based clinical practice guidelines (8th ed). Chest. 2008; 133 (Suppl): 776S-814S. [PubMed 18574278]

20. Antman EM, Hand M, Armstrong PW et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction. J Am Coll Cardiol. 2008; 51:210-47. [PubMed 18191746]

21. Goodman SG, Menon V, Cannon CP et al. Acute ST-segment elevation myocardial infarction: American College of Chest Physicians evidenced-based clinical practice guidelines (8th ed). Chest. 2008; 133 (Suppl):708S-75S. [PubMed 18574277]

22. Schulman S, Beyth RJ, Kearon C et al. Hemorrhagic complications of anticoagulant and thrombolytic treatment: American College of Chest Physicians evidenced-based clinical practice guidelines (8th ed). Chest. 2008; 133 (Suppl):257S-98S. [PubMed 18574268]

23. Anderson JL, Adams CD, Antman EM et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction). Available at ACC website. Accessed 2008 Oct 15.

24. Koster A, Dyke CM, Aldea G et al. Bivalirudin during cardiopulmonary bypass in patients with previous or acute heparin-induced thrombocytopenia and heparin antibodies: results of the CHOOSE-ON trial. Ann Thorac Surg. 2007; 83:572-7.

25. Lewis SZ (American College of Chest Physicians, Northbrook, IL): Personal communication. 2011 Mar 15.

26. Dyke CM, Aldea G, Koster A et al. Off-pump coronary artery bypass with bivalirudin for patients with heparin-induced thrombocytopenia or antiplatelet factor four/heparin antibodies. Ann Thorac Surg. 2007; 84:836-40.

b. Robson R, White H, Aylward P et al. Bivalirudin pharmacokinetics and pharmacodynamics: effect of renal function, dose, and gender. Clin Pharmacol Ther. 2002; 71:433-39. [PubMed 12087346]

HID. Trissel LA. Handbook on injectable drugs. 14th ed; Bethesda, MD: American Society of Health-System Pharmacists; 2007:207-13.

More Angiomax resources

• Angiomax Side Effects (in more detail)
• Angiomax Use in Pregnancy & Breastfeeding
• Angiomax Drug Interactions
• Angiomax Support Group
• 0 Reviews for Angiomax - Add your own review/rating

• Angiomax Prescribing Information (FDA)


• Angiomax MedFacts Consumer Leaflet (Wolters Kluwer)


• Angiomax Concise Consumer Information (Cerner Multum)


• Angiomax Advanced Consumer (Micromedex) - Includes Dosage Information


• Bivalirudin Professional Patient Advice (Wolters Kluwer)

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