Direct Thrombin Inhibitor — HIT / Endovascular Procedures Pregnancy: Use only if clearly necessary — limited data; potential anticoagulant effects in neonate

Bivalirudin

Brand names: Angiox

Adult dose

Dose: PCI: 0.75 mg/kg IV bolus then 1.75 mg/kg/hour infusion during procedure; HIT with thrombosis: 0.15–0.2 mg/kg/hour adjusted to aPTT 1.5–2.5× normal

Route: Intravenous

Frequency: Continuous infusion (procedure-based or weight-adjusted)

Max: 1.75 mg/kg/hour during PCI

Short half-life (25 minutes) — stops working rapidly on discontinuation. Predominantly non-renally cleared (80% enzymatic degradation) — safer than argatroban in hepatic failure. Reduce infusion rate to 1 mg/kg/hour if CrCl <30 mL/min. No antidote — manage bleeding by stopping infusion.

Paediatric dose

Route:

Seek specialist opinion — limited paediatric data

Dose adjustments

Renal

CrCl 10–29: reduce infusion to 1 mg/kg/hour; haemodialysis: 0.25 mg/kg/hour; monitor aPTT

Hepatic

No adjustment required — minimal hepatic metabolism (advantage over argatroban)

Clinical pearls

Direct thrombin inhibitor — inhibits both free and clot-bound thrombin (advantage over heparins which only inhibit free thrombin)
HIT: bivalirudin and argatroban are the two preferred alternatives when heparin must be stopped — bivalirudin preferred in hepatic failure, argatroban in renal failure
Short half-life means rapid offset — monitor aPTT every 3 hours initially
HORIZONS-AMI trial: bivalirudin during STEMI PCI reduced major bleeding vs heparin + GPIIb/IIIa; less antiplatelet combination now standard
No antidote available — bleeding managed by stopping infusion and supportive measures

Contraindications

Active major bleeding
Hypersensitivity to bivalirudin or hirudins

Side effects

Bleeding
Back pain
Nausea
Headache
Hypotension
Thrombocytopaenia (rare)

Interactions

Anticoagulants — additive bleeding
Thrombolytics — major bleeding risk
Antiplatelets (GPIIb/IIIa inhibitors) — additive bleeding in PCI

Monitoring

aPTT (target 1.5–2.5× baseline for HIT indication)
ACT during PCI
FBC
Renal function
Signs of bleeding

Reference: BNFc; BNF 90; ACCP Antithrombotic Therapy Guidelines; HORIZONS-AMI Trial; ASH HIT Guidelines 2018. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways