ClinCalc Pro
Menu
Calculators Drugs Pathways AI Dx Donate Get the App
Anticoagulation Pregnancy: Use only if benefit clearly outweighs risk — limited data; seek specialist haematology advice

Bivalirudin

Brand names: Angiox

Adult dose

Dose: 0.75 mg/kg IV bolus then 1.75 mg/kg/hour infusion
Route: IV
Frequency: Bolus then continuous infusion
Max: 1.75 mg/kg/hour
For PCI: bolus then infusion during procedure; post-procedure: 0.25 mg/kg/hour for up to 4 hours. For HIT with ACS: 0.1 mg/kg/hour without bolus

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: IV
Frequency: N/A
Max: N/A
Not established in paediatrics; seek specialist paediatric haematology or cardiology opinion

Dose adjustments

Renal

Reduce infusion rate: GFR 30–59 → 1.4 mg/kg/hour; GFR under 30 → 1 mg/kg/hour; dialysis-dependent → 0.25 mg/kg/hour

Hepatic

No specific dose adjustment — bivalirudin undergoes enzymatic and renal elimination; use with caution in severe hepatic impairment

Paediatric weight-based calculator

Not established in paediatrics; seek specialist paediatric haematology or cardiology opinion

Clinical pearls

  • Mechanism: direct thrombin inhibitor — bivalirudin binds to both the catalytic site and exosite-1 of thrombin; unlike heparin, NO antithrombin III dependence; inhibits both free and clot-bound thrombin
  • KEY ADVANTAGE in HIT: because bivalirudin does not cause HIT and has predictable kinetics, it is the preferred anticoagulant for patients with HIT who need PCI or anticoagulation — argatroban is alternative
  • HORIZONS-AMI trial: bivalirudin vs heparin + GPIIb/IIIa in STEMI PCI — 30-day major bleeding significantly lower with bivalirudin (4.9% vs 8.3%), but acute stent thrombosis higher (1.3% vs 0.3%)
  • Short half-life (25 minutes) — advantage in bleeding situations; anticoagulant effect dissipates quickly on stopping infusion; NO specific reversal agent available
  • MHRA: licensed for ACS managed with PCI; off-label for HIT treatment — consult haematology
  • APTT monitoring is NOT routinely required (unlike heparin) — bivalirudin has predictable linear pharmacokinetics; ACT monitoring used during PCI

Contraindications

  • Active major bleeding
  • Severe uncontrolled hypertension
  • Subacute bacterial endocarditis
  • Haemorrhagic stroke within 3 months

Side effects

  • Bleeding (major and minor)
  • Nausea
  • Hypotension
  • Thrombocytopenia (rare — unlike heparin, not immune-mediated)
  • Acute stent thrombosis (HORIZONS-AMI — higher rate vs heparin in STEMI)

Interactions

  • Other anticoagulants (additive bleeding — avoid concurrent use unless dose adjustment)
  • Antiplatelet agents (increased bleeding risk — monitor)
  • Thrombolytics (AVOID combination — major haemorrhage risk)

Monitoring

  • ACT (activated clotting time) during PCI — target 350–450 seconds
  • Signs of bleeding
  • Platelet count (HIT context — monitor to confirm recovery)
  • Renal function (dose adjustment required)

Reference: BNFc; BNF 90; ESC NSTE-ACS Guidelines 2020; HORIZONS-AMI trial NEJM 2008;358(21):2218-2230; NICE TA230. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

Calculators
Pathways