Argatroban Infusion Protocol To calculate standard initial infusion rate (ml/hr):1mcg/kg/min x weight (kg) x 60mins 1000mcg/ml Table 1 Initial Rate of Argatroban Infusion (concentration 1mg/ml) Body weight (kg) Standard dosing Infusion Rate (ml/hr) * 1 microgram/kg/min Critically ill or hepatically impaired patients (Child-Pugh class B) and pos Argatroban Dosing Guidelines For Prevention & Treatment of Thrombosis in Heparin-Induced Thrombocytopenia (HIT) 1. Before starting Argatroban: Stop all heparin (including catheter flushes), enoxaparin or dalteparin, and warfarin Obtain baselines labs (if none in past 24 hours)- CBC, PTT, PT/INR, Basic Metabolic Profile, LFT Dilute argatroban 250mg in either 250mL sodium chloride 0.9% or 250mL glucose 5% to give a final concentration of 1mg/mL. The optimal range for argatroban is APTT ratio 1.5 - 3.0 Check APTT ratio 2 hours after starting infusion, then adjust rate to achieve therapeutic range of 1.5 - 3.0 using the dose adjustment table
Argatroban is monitored using the activated partial thromboplastin time (aPTT). The goal aPTT in seconds has been defined at UWMC/HMC as 60-80 seconds. Alternatively, it can be monitored with the direct thrombin inhibitor assay available at UWMC/HMC. This assay has a therapeutic range of 60 - 100 seconds for argatroban (different for other DTIs) When platelets > 150,000, initiate the Argatroban to Warfarin Transition Protocol. Pharmacy will dose warfarin and manage daily using the protocol. Monitoring PTT 4 hours after infusion started or any infusion rate change PTT every morning if no infusion rate change in past 24 hours CBC every morning 1 2.5-5 mg PO daily and overlap with argatroban for a minimum of 5 days If argatroban rate â‰¤ 2 mcg/kg/minute and INR > 4, stop infusion and obtain INR 4 hours after stopping infusion INR 2-3: continue with warfarin monotherapy INR < 2: restart argatroban and repeat above steps the following da also higher. Conclusions: Low dose of argatroban saline flushes is a feasible and safe alternative anticoagulation protocol in HD patients with high risk of bleeding. Keywords: hemodialysis; blood purification; anticoa-gulation; argatroban; bleeding; hemorrhage Introduction Anticoagulation is generally required for effectiv Argatroban 50 mg vial 158.18 Bivalirudin 250 mg vial 910.50 Fondaparinux 7.5 mg dose 102.89 Definitions2 1. Heparin induced thrombocytopenia (HIT): immune mediated drug reaction resulting in platelet activation, increased thrombin production and increased risk for venous and arterial thrombosis. 2. Isolated HIT: HIT without thrombosis 3
on IV argatroban 1 mcg/kg/min. Once access via the popliteal vein was secured, the argatroban infusion was transferred over to be infused at 0.8 mcg/kg/min through the sidearm of the popliteal venous sheath with a goal aPTT of 40-50 seconds. Alteplase (50 mg in 500 mL 0.9% sodium chloride) was infused via the medication lumen of the EKOSÂ Guidelines for the use of argatroban in HIT. Please see the attached document. Note that argatroban is a NONFORMULARY drug at UW Medicine. Bivalirudin is the preferred agent. Attachment: argatroban.pdf
argatroban infusion standardâ‚¬ Premix IV 50 mL 0.5 mcg/kg/min Inj Argatroban LOW Dose Nomogram Start initial infusion at 0.5 mcg/kg/min, Repeat aPTT 2 hour after initiation of argatroban. aPTT HOLD Rate Change Repeat aPTT (sec) for (min) < 59 0 increase rate by 2 hours after 0.25 mcg/kg/min rate increase 60 -10 Warfarin (Coumadin) dosing guide for patients on Argatroban infusion 1. Baseline PT/INR at protocol initiation, then at least daily INR with am labs. 2. Daily orders must be written for warfarin doses based on daily INR evaluation. Patient will be evaluated daily for symptoms of bleeding. 3 ARGATROBAN PROTOCOL FOR HEPARIN-INDUCED THROMBOCYTOPENIA, PAGE 3 of 3 INFUSION FLOW CHART AND TITRATION TABLE Argatroban Standard Concentration 125mg/125ml (1mg/ml) Patient Weight (kg) Standard (Normal liver function) Hepatic Impairment Critically Ill + Multi-organ Failure Initial: 2 mcg/kg/min Titration
priming protocol. c. Loading dose of Argatroban for ECMO Circuitry is 50 mcg per 750 mL of prime d. Ensure ACT >1000 before connection to patient ii. Patient Anticoagulation with Initial Cannulation (Argatroban therapy is to be started 30 minutes prior to initiation of ECMO): a. Bolus Patient with 100 mcg/kg IV b inhibitors lepirudin/RefludanÂ®, argatroban/ArgatrobanÂ®, bivalirudin/AngiomaxÂ®, dabigatran/PradaxaÂ®), desirudin/IprivaskÂ® (note that desirudin/IprivaskÂ® is not currently on formulary at all Cleveland Clinic Health System Pharmacies) the thrombolytic agents: alteplase/ActivaseÂ® or tenecteplase TNKase
argatroban for 4 hours, then check the INR. If the INR is <2.0, restart argatroban and consider warfarin dose adjustment. Repeat process every 24-48 hours until the INR is â‰¥2.0. If the INR is â‰¥2.0, and at least a 5-day warfarin-argatroban overlap has been achieved, discontinue argatroban and continue warfarin (1.7-7.0) during argatroban monotherapy, 68.6 (44.5 -104) and 5.3 (2.4-16) maximally during cotherapy, 59.9 (38.7-92.2) and 4.0 (2.2-11.6) immediately before argatroban cessation during cothera-py, and 36.0 (25.6-60.2) and 2.3 (1.3-7.3) within a median 10-12 hours after argatroban cessation. Major bleeding occurred in Argatroban was held for 36 hours after surgery. During this period, his activated partial thromboplastin time (aPTT) ranged between 25.4 - 33.8 s. After that, argatroban was re-started and the aPTT kept between 48-55 s. On post-operative day (POD) 3, doppler studies revealed a venous thrombus in the right upper extremity Argatroban is a synthetic, nonpeptide small molecular weight (~500 Da) L-arginine derivative that reversibly inhibits thrombin by means of univalent binding to the active site (exosite 3; fig. 1A). 6 Argatroban is recommended for use in patients with renal failure as it undergoes hepatic elimination with a half-life of 40 to 50 min, but can be prolonged with moderate to severe hepatic.
argatroban was 0.3-0.7 mL/min/kg, suggest-ing an increase of 20% in argatroban clear-ance (15). Management and Monitoring of Anticoagulation At the beginning of CRRT, all patients re-ceived argatroban at a dose of 100 g/kg as a bolus injection followed by a continuous infu-sion of 1 g/kg/min. Argatroban was applie Nineteen patients received either argatroban or lepirudin prior to HIT-protocol implementation, while the remaining ten received either drug after the HIT protocol was implemented. Intervention: Implementation of HIT protocol occurred in March 2009. Patients were divided into pre-protocol and post-protocol groups If argatroban therapy is used concurrently with or following FFP or a thrombolytic, some centers decrease dose by half. Heparin-induced thrombocytopenia: Initial dose: 0.75 mcg/kg/minute by continuous IV infusion. Maintenance dose: Measure aPTT after 2 hours; adjust dose until the steady-state aPTT is 1.5 to 3 times the initial baseline value. Argatroban is a white, odorless crystalline powder that is freely soluble in glacial acetic acid, slightly soluble in ethanol, and insoluble in acetone, ethyl acetate, and ether. Argatroban Injection 50 mg/50 mL (1 mg/mL) is a sterile clear, colorless to pale yellow, solution Argatroban orders and dosing protocol  PHYSICIAN ORDERS PATIENT INFORMATION ( ) argatroban infusion - Routine Infusion STAT, IntraVENous, 2 mcg/kg/min, Continuous Do not start Argatroban if baseline PTT is greater than 70 seconds. Recheck PTT in 4 hours. Initiate argatroban when baseline PTT is less than 70 seconds
Consensus protocols for the plasma exchange and intraoperative heparin strategy and for the intraoperative heparin and potent antiplatelet agent strategy have not been established. If either of these strategies is used, treatment with heparin is limited to the intraoperative setting and avoided before and after surgery ^ Including argatroban, bivalirudin, or lepirudin, and possibly fondaparinux. DO NOT USE WARFARIN UNTIL THE PLATELET COUNT HAS RECOVERED TO > 150,000 per Î¼L. 3. Choice of alternative anticoagulation (if applicable, see Table 4 . Wafarin (Coumadin) Inhibits Vitamin K-dependant factors II, VII, IX, and X and proteins C, S, and Z. Licensed healthcare provider initiates Nurse Driven protocol. Argatroban ts Warfarin 1. For those with active clot or high risk for clotting, there must be a five day overlap of both drugs AND 2. Achieve single therapeutic INR â‰¥ 2 prior to stopping heparin infusion. 1. Wait 3 hours after discontinuation of heparin infusion to start argatroban infusion. 2. Refer to VCMC Adult Argatroban Drip Protocol
Abstract. Argatroban and bivalirudin are two direct thrombin inhibitors (DTI) employed to treat heparin-induced thrombocytopenia (HIT). Following the withdrawal of lepirudin in 2012 we needed to establish in-house therapeutic ranges and dosing schedules for both DTI, since their practical handling was not clearly defined Argatroban as an Alternative to Heparin for Vascular and Cardiovascular Surgery in Patients with a History of HIT. By April Schmidt, RN, BSN. Duke University Nurse Anesthesia Program. My Background:BSN from East Carolina University in 1999. Pitt County Memorial HospitalSIU & PACU-3yrs
Guidelines for the Management of Anticoagulant and Anti-Platelet Agent Associated Bleeding Complications in Adults Purpose: To be used as a common tool for all practitioners involved in the care of patients who present with bleeding problems related to use of anticoagulant and anti-platelet agents Argatroban is a new fast-acting synthetic thrombin inhibitor derived from arginine (Coron Art Dis 1996;7:455-58). The safety profile, as revealed in the original ARGAMI trial, suggests argatroban may have some advantages over heparin in select patients following myocardial infarction (MI). Although no statistically significant differences were. Extracorporeal membrane oxygenation (ECMO) have become more frequently used in daily ICU practice, heparin-induced thrombocytopenia (HIT) is a rare but life-threatening complication while on extracorporeal membrane oxygenation (ECMO). HIT confirmation directly impacts on anticoagulant strategy requiring no delay unfractionated heparin discontinuation to be replaced by alternative systemic. Argatroban is highly selective for thrombin with an inhibitory constant (K. i) of 0.04 ÂµM. At therapeutic concentrations, Argatroban has little or no effect on related serine proteases (trypsin, factor Xa, plasmin, and kallikrein). Argatroban is capable of inhibiting the action of both free and clot-associated thrombin
Therefore, alternative regimens using argatroban are described below (Appendix A & B). 3.3 Care of recipient Post-transplant care of recipient of an organ from a donor with definite or probable VITT o In most respects, care will be as per standard protocols. Thromboprophylaxis can be given in the normal way unless VITT is suspected Anticoagulation in patients with heparin-induced thrombocytopenia type II who require parenteral antithrombotic treatment. Initially 2 micrograms/kg/minute, dose to be adjusted according to activated partial thromboplastin time, (by intravenous infusion) increased to up to 10 micrograms/kg/minute maximum duration of treatment 14 days
Argatroban administration is usually governed by local protocols that incorporate an initial dose, aPTT monitoring and increments or reductions in the dose of argatroban. Using a protocol to titrate the dose of argatroban has been shown to improve the quality of anticoagulation that a patient receives; time to goal aPTT and the time with goal aPTT are better than without a protocol Argatroban is a white, odorless crystalline powder that is freely soluble in glacial acetic acid, slightly soluble in ethanol, and insoluble in acetone, ethyl acetate, and ether.. Argatroban Injection is a sterile clear, colorless to pale yellow, slightly viscous solution in a single-use amber vial containing 250 mg/2.5 mL of argatroban Unfractionated heparin (UFH) binds to anti-thrombin III (AT-III), which enhances antithrombin's inhibition of several coagulation factors - especially factor Xa and factor IIa (thrombin). Low Molecular-Weight Heparin (LMWH) is a heterogeneous collection of heparin molecules with a lower average molecular weight compared to unfractionated heparin OBJECTIVE: Argatroban, a direct thrombin inhibitor, was evaluated for anticoagulation in continuous renal replacement therapy (CRRT) in critically ill patients with heparin-induced thrombocytopenia type II and acute renal failure. The investigation focused on predictors for the maintenance doses of argatroban with efficacy and safety of. Argatroban is a direct, selective thrombin inhibitor. The American College of Cardiologists (ACC) recommend using bivalirudin or argatroban in patients who have had, or at risk for, heparin induced thrombocytopenia (HIT) and are undergoing percutaneous coronary intervention. Argatroban is a non-heparin anticoagulant shown to both normalize platelet count in patients with HIT and prevent the.
Argatroban lacks major drug-drug interactions with CYP3A4/5 inhibitors such as erythromycin or with acetaminophen, warfarin, and digoxin. However, in patients with hepatic impairment, area under the concentration versus time curve (AUC), maximum concentration, and half-life of argatroban were increased approximately 2- to 3-fold, and clearance was one-fourth that of healthy volunteers Argatroban dosage requirements and outcomes in intensive care versus non-intensive care patients. Smythe MA(1), Koerber JM, Forsyth LL, Priziola JL, Balasubramaniam M, Mattson JC. Author information: (1)Departments of Pharmaceutical Services, William Beaumont Hospital, Royal Oak, Michigan 48073, USA argatroban, bivalirudin, or danaparoid (see Table 2). This applies to all HIT, with or without thrombosis. The efficacy and safety of the newer oral anticoagulants have not been established in HIT. Consider if the patient may already have a thromboembolic event. Patients wit Argatroban was then administered as a bolus of 8.5 mg (150 Î¼g/kg) followed by an infusion at 5 Î¼g Â· kg âˆ’1 Â· min âˆ’1. Coagulation variables were repeated at 15-min intervals, and the infusion rate was titrated to maintain an ACT at or more than approximately 200 s per cardiovascular protocol at our institution
Argatroban (if heparin-induced thrombocytopenia [HIT]), dosed according to institutional protocol. Fondaparinux (if HIT and creatinine clearance greater than or equal to 50 ml/min) dosed by weight: â‰¥100 kg: 10 mg daily <100 kg but â‰¥50 kg: 7.5 mg dail Argatroban (Acova) â€” 2 mcg per kg per Alternatively follow bridge therapy protocolâ€ using prophylactic LMWH or unfractionated heparin after surgery. 2C. High-risk thromboembolism
The primary efficacy objective of the MOST trial is to determine if argatroban (100Âµg/kg bolus followed by 3Âµg/kg per minute for 12 hours) or eptifibatide (135Âµg/kg bolus followed by .75Âµg/kg/min infusion for two hours) results in improved 90-day modified Rankin scores (mRS) as compared with placebo in acute ischemic stroke (AIS) patients treated with .9mg/kg IV rt-PA within three hours. This is an update of the previous published guideline in 2006. It addresses the problem of thrombocytopenia developing in patients receiving heparin therapy and emphasises the importance of diagnosing heparin induced thrombocytopenia as a serious complication of therapy with a high morbidity and mortality Research Article Therapeutic Anticoagulation with Argatroban and Heparins Reduces Granulocyte Migration: Possible Impact on ECLS-Therapy? Andre Bredthauer ,1 Manuel Kopfmueller,1,2 Michael Gruber ,1 Sophie-Marie Pfaehler,1 Karla Lehle,3 Walter Petermichl,1 Timo Seyfried,1 Diane Bitzinger ,1 and Andreas Redel1,4 1Department of Anesthesiology, University Medical Center Regensburg, Regensburg.
Free flap anticoagulation protocols Argatroban. Mechanism of action: Argatroban is a synthetic direct thrombin inhibitor that reversibly binds to the thrombin active site. Its anticoagulant effects are achieved by inhibiting thrombin-catalyzed or -induced reactions, including fibrin formation; activation of coagulation factors V,. Administration protocol. For the argatroban group, the nurses will aspirate 4 mL of argatroban (20 mL/10 mg, produced by TIPR Pharmaceutical Responsible Co., Ltd, Tianjin, China) into a 5-mL syringe and produce 4 mL of argatroban 0.5 mg/mL as the lock agent per patient per dialysis run (2 mL for both venous and arterial lumen) Appendix A: Protocol for the use of Argatroban in organ retrieval Controlled if copy number stated on document and issued by QA (Template Version 03/02/2020) Page 4 of 7 CONTROLLED -DBD and DCD. V2. 16.04.21 Background Donor surgery may require organ retrieval without the use of heparin in cases where there is