Bivalirudin (Angiomax)
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Bivalirudin (Angiomax)

ANGIOMAX®
(bivalirudin) for Injection, for Intravenous Use

DRUG DESCRIPTION

Angiomax (bivalirudin) is a specific and reversible direct thrombin inhibitor. The active substance is a synthetic, 20 amino acid peptide. The chemical name is D-phenylalanyl-L-prolyl-L-arginyl-L-prolyl-glycylglycyl-glycyl-glycyl-L-asparagyl-glycyl-L-aspartyl-L-phenylalanyl-L-glutamyl-L-glutamyl-L-isoleucyl-L-prolyl-L-glutamyl-L-glutamyl-L-tyrosyl-L-leucine trifluoroacetate (salt) hydrate (Figure 1). The molecular weight of Angiomax (bivalirudin) is 2180 daltons (anhydrous free base peptide).

Angiomax (bivalirudin) is supplied in single-use vials as a white lyophilized cake, which is sterile. Each vial contains 250 mg bivalirudin, 125 mg mannitol, and sodium hydroxide to adjust the pH to 5-6 (equivalent of approximately 12.5 mg sodium). When reconstituted with Sterile Water for Injection, the product yields a clear to opalescent, colorless to slightly yellow solution, pH 5-6.

Figure 1. Structural Formula for Bivalirudin

ANGIOMAX® (bivalirudin) Structural Formula Illustration

What are the possible side effects of bivalirudin (Angiomax)?

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Call your doctor at once if you have any of these serious side effects:

  • sudden numbness or weakness, especially on one side of the body;
  • sudden headache, confusion, problems with vision, speech, or balance;
  • pain or swelling in one or both legs;
  • any bleeding that will not stop;
  • black, bloody, or tarry stools;
  • coughing up blood or vomit that looks like coffee...

Read All Potential Side Effects and See Pictures of Angiomax »

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

INDICATIONS

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Angiomax® (bivalirudin) is indicated for use as an anticoagulant in patients with unstable angina undergoing percutaneous transluminal coronary angioplasty (PTCA).

Percutaneous Coronary Intervention (PCI)

Angiomax (bivalirudin) with provisional use of glycoprotein IIb/IIIa inhibitor (GPI) as listed in the REPLACE-2 trial [see Clinical Studies] is indicated for use as an anticoagulant in patients undergoing percutaneous coronary intervention (PCI).

Angiomax (bivalirudin) is indicated for patients with, or at risk of, heparin induced thrombocytopenia (HIT) or heparin induced thrombocytopenia and thrombosis syndrome (HITTS) undergoing PCI.

Use with Aspirin

Angiomax (bivalirudin) in these indications is intended for use with aspirin and has been studied only in patients receiving concomitant aspirin [see DOSAGE AND ADMINISTRATION and Clinical Studies].

Limitation of Use

The safety and effectiveness of Angiomax (bivalirudin) have not been established in patients with acute coronary syndromes who are not undergoing PTCA or PCI.

DOSAGE AND ADMINISTRATION

Recommended Dose

Angiomax (bivalirudin) is for intravenous administration only.

Angiomax (bivalirudin) is intended for use with aspirin (300-325 mg daily) and has been studied only in patients receiving concomitant aspirin.

For patients who do not have HIT/HITTS

The recommended dose of Angiomax (bivalirudin) is an intravenous (IV) bolus dose of 0.75 mg/kg, followed by an infusion of 1.75 mg/kg/h for the duration of the PCI/PTCA procedure. Five min after the bolus dose has been administered, an activated clotting time (ACT) should be performed and an additional bolus of 0.3 mg/kg should be given if needed.

GPI administration should be considered in the event that any of the conditions listed in the REPLACE-2 clinical trial description [see Clinical Studies] is present.

For patients who have HIT/HITTS

The recommended dose of Angiomax (bivalirudin) in patients with HIT/HITTS undergoing PCI is an IV bolus of 0.75 mg/kg. This should be followed by a continuous infusion at a rate of 1.75 mg/kg/h for the duration of the procedure.

For ongoing treatment post procedure

Continuation of the Angiomax (bivalirudin) infusion following PCI/PTCA for up to 4 hours post-procedure is optional, at the discretion of the treating physician. After four hours, an additional IV infusion of Angiomax (bivalirudin) may be initiated at a rate of 0.2 mg/kg/h (low-rate infusion), for up to 20 hours, if needed.

Dosing in Renal Impairment

No reduction in the bolus dose is needed for any degree of renal impairment. The infusion dose of Angiomax (bivalirudin) may need to be reduced, and anticoagulant status monitored in patients with renal impairment. Patients with moderate renal impairment (30-59 mL/min) should receive an infusion of 1.75 mg/kg/h. If the creatinine clearance is less than 30 mL/min, reduction of the infusion rate to 1 mg/kg/h should be considered. If a patient is on hemodialysis, the infusion rate should be reduced to 0.25 mg/kg/h [see Use In Specific Population].

Instructions for Administration

Angiomax (bivalirudin) is intended for intravenous bolus injection and continuous infusion after reconstitution and dilution. To each 250 mg vial, add 5 mL of Sterile Water for Injection, USP. Gently swirl until all material is dissolved. Each reconstituted vial should be further diluted in 50 mL of 5% Dextrose in Water or 0.9% Sodium Chloride for Injection to yield a final concentration of 5 mg/mL (e.g., 1 vial in 50 mL; 2 vials in 100 mL; 5 vials in 250 mL). The dose to be administered is adjusted according to the patient's weight (See Table 1).

If the low-rate infusion is used after the initial infusion, a lower concentration bag should be prepared. In order to prepare this bag, reconstitute the 250 mg vial with 5 mL of Sterile Water for Injection, USP. Gently swirl until all material is dissolved. Each reconstituted vial should be further diluted in 500 mL of 5% Dextrose in Water or 0.9% Sodium Chloride for Injection to yield a final concentration of 0.5 mg/mL. The infusion rate to be administered should be selected from the right-hand column in Table 1.

Table 1 : Dosing Table

Weight(kg) Using 5 mg/mL Concentration Using 0.5 mg/mL Concentration
Bolus 0.75 mg/k(mL) Infusion 1.75 mg/kg/h (mL/h) Subsequent Low-rate Infusion 0.2 mg/kg/h
(mL/h)
43-47 7 16 18
48-52 7.5 17.5 20
53-57 8 19 22
58-62 9 21 24
63-67 10 23 26
68-72 10.5 24.5 28
73-77 11 26 30
78-82 12 28 32
83-87 13 30 34
88-92 13.5 31.5 36
93-97 14 33 38
98-102 15 35 40
103-107 16 37 42
108-112 16.5 38.5 44
113-117 17 40 46
118-122 18 42 48
123-127 19 44 50
128-132 19.5 45.5 52
133-137 20 47 54
138-142 21 49 56
143-147 22 51 58
148-152 22.5 52.5 60

Angiomax (bivalirudin) should be administered via an intravenous line. No incompatibilities have been observed with glass bottles or polyvinyl chloride bags and administration sets. The following drugs should not be administered in the same intravenous line with Angiomax (bivalirudin) , since they resulted in haze formation, microparticulate formation, or gross precipitation when mixed with Angiomax (bivalirudin) : alteplase, amiodarone HCl, amphotericin B, chlorpromazine HCl, diazepam, prochlorperazine edisylate, reteplase, streptokinase, and vancomycin HCl. Dobutamine was compatible at concentrations up to 4 mg/mL but incompatible at a concentration of 12.5 mg/mL.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Preparations of Angiomax (bivalirudin) containing particulate matter should not be used. Reconstituted material will be a clear to slightly opalescent, colorless to slightly yellow solution.

Storage after Reconstitution

Do not freeze reconstituted or diluted Angiomax (bivalirudin) . Reconstituted material may be stored at 2-8°C for up to 24 hours. Diluted Angiomax (bivalirudin) with a concentration of between 0.5 mg/mL and 5 mg/mL is stable at room temperature for up to 24 hours. Discard any unused portion of reconstituted solution remaining in the vial.

HOW SUPPLIED

Dosage Forms And Strengths

Angiomax (bivalirudin) is supplied as a sterile, lyophilized powder in single-use, glass vials. After reconstitution, each vial delivers 250 mg of Angiomax (bivalirudin) .

Storage And Handling

Angiomax (bivalirudin) is supplied as a sterile, lyophilized powder in single-use, glass vials. After reconstitution, each vial delivers 250 mg of Angiomax (bivalirudin) .

NDC 65293-001-01

Store Angiomax (bivalirudin) dosage units at 20-25°C (68-77°F). Excursions to 15-30°C permitted. [See USP Controlled Room Temperature.]

Manufactured by: BenVenue Laboratories Bedford, OH. Distributed by: ICS Louisville, KY. Marketed by: The Medicines Company Parsippany, NJ 07054. For information call: (800) 264-4662. Revised: 06/2010

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

SIDE EFFECTS

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Bleeding

In 6010 patients undergoing PCI treated in the REPLACE-2 trial, Angiomax (bivalirudin) patients exhibited statistically significantly lower rates of bleeding, transfusions, and thrombocytopenia as noted in Table 2.

Table 2: Major Hematologic Outcomes REPLACE-2 Study (Safety Population)

  Angiomax with “provisional” GPI1
n=2914
HEPARIN + GPI
(n=2987)
p-value
Protocol defined major hemorrhage2 (%) 2.3% 4.0% < 0.001
Protocol defined minor hemorrhage3 (%) 13.6% 25.8% < 0.001
TIMI defined bleeding4      
- Major 0.6% 0.9% 0.259
- Minor 1.3% 2.9 < 0.001
Non-access site bleeding
- Retroperitoneal bleeding 0.2% 0.5% 0.069
- Intracranial bleeding <0.1% 0.1% 1.0
Access site bleeding
- Sheath site bleeding 0.9% 2.4% < 0.001
Thrombocytopenia5
< 100,000 0.7% 1.7% < 0.001
< 50,000 0.3% 0.6% 0.039
Transfusions
- RBC 1.3% 1.9% 0.08
- Platelets 0.3% 0.6% 0.095
1 GPIs were administered to 7.2% of patients in the Angiomax (bivalirudin) with provisional GPI group
2 Defined as the occurence of any of the following: intracranial bleeding, retroperitoneal bleeding, a transfusion of ≥ 2 units of blood/blood products, a fall in hemoglobin > 4g/dL, whether of not bleeding site is identified, spontaneous or non-spontaneous blood loss with a decrease in hemoglobin > 3g/Dl
3 Defined as observed bleeding that does not meet the criteria for major hemorrhage
4 TIMI major bleeding is defined as intracranial, or a fall in adjusted Hgb > 5g/dL or Hct of > 15%: TIMI minor bleeding is defined as a fall in adjusted Hgb of 3 to < 5 g/dL or a fall in adjusted Hct of 9 to < 15%, with a bleeding site such as hematuria, hematemesis, hematomas, retroperitoneal bleeding or a decrease in Hgb of > 4 g/dL with no bleeding site
5 If < 100,000 and > 25% reduction from baseline, or < 50,000

In 4312 patients undergoing PTCA for treatment of unstable angina in 2 randomized, double-blind studies comparing Angiomax (bivalirudin) to heparin, Angiomax (bivalirudin) patients exhibited lower rates of major bleeding and lower requirements for blood transfusions. The incidence of major bleeding is presented in Table 3. The incidence of major bleeding was lower in the Angiomax (bivalirudin) group than in the heparin group.

Table 3: Major Bleeding and Transfusions in BAT Trial (all patients)1

  Angiomax
N=2161
Heparin
N=2151
No. (%) Patients with Major hemorrhage 2 79 (3.7) 199 (9.3)
  - with ≥ 3 g/dL fall in Hgb 41 (1.9) 124 (5.8)
  - with ≥ 5 g/dL fall in Hgb 14 (0.6) 47 (2.2)
  - retroperitoneal bleeding 5 (0.2) 15 (0.7)
  - intracranial bleeding 1 (<0.1) 2 (0.1)
  - Required transfusions 43 (2.0) 123 (5.7)
1 No monitoring of ACT (or PTT) was done after a target ACT was achieved.
2 Major hemorrhage was defined as the occurence of any of the following, intracranial bleeding, retroperitoneal bleeding, clinically overt bleeding with a decrease in hemoglobin ≥ 3 g/dL or leading to a transfusion of ≥ 2 units of blood. This table includes data from the entire hospitalization period.

In the AT-BAT study, of the 51 patients with HIT/HITTS, 1 patient who did not undergo PCI had major bleeding during CABG on the day following angiography. Nine patients had minor bleeding (mostly due to access site bleeding), and 2 patients developed thrombocytopenia.

Other Adverse Reactions

Adverse reactions, other than bleeding, observed in clinical trials were similar between the Angiomax (bivalirudin) treated patients and the control groups.

Adverse reactions (related adverse events) seen in clinical studies in patients undergoing PCI and PTCA are shown in Tables 4 and 5.

Table 4 : Most frequent ( ≥ 0.2%) treatment-related adverse events (reactions) (through 30 days) in the REPLACE-2 Safety population

  Angiomax (bivalirudin) with “provisional” GPI1
(N= 2914)
Heparin + GPI
(N =2987)
n (%) n (%)
Patients with at least one treatment-related AE 78 (2.7) 115 (3.9)
Thrombocytopenia 9 (0.3) 30 (1.0)
Nausea 15 (0.5) 7 (0.2)
Hypotension 7 (0.2) 11 (0.4)
Angina pectoris 5 (0.2) 12 (0.4)
Headache 6 (0.2) 5 (0.2)
Injection site pain 3 (0.1) 8 (0.3)
Nausea and vomiting 2 (0.1) 6 (0.2)
Vomiting 3 (0.1) 5 (0.2)
Note: A patient could have more than one event in any category.
Abbreviation: AE = adverse event.

 Table 5: Adverse Events Other Than Bleeding Occurring In ≥ 5% Of Patients In Either Treatment Group In BAT Trial

EVENT Treatment Group
ANGIOMAX
N=2161
HEPARIN
N=2151
Number of Patients(%)
CARDIOVASCULAR
  Hypotension 262 (12) 371 (17)
  Hypertension 135 (6) 115 (5)
  Bradycardia 118 (5) 164 (8)
GASTROINTESTINAL
  Nausea 318 (15) 347 (16)
  Vomiting 138 (6) 169 (8)
  Dyspepsia 100 (5) 111 (5)
GENITOURINARY
  Urinary retention 89 (4) 98 (5)
MISCELLANEOUS
  Back pain 916 (42) 944 (44)
  Pain 330 (15) 358 (17)
  Headache 264 (12) 225 (10)
  Injection site pain 174 (8) 274 (13)
  Insomnia 142 (7) 139 (6)
  Pelvic pain 130 (6) 169 (8)
  Anxiety 127 (6) 140 (7)
  Abdominal pain 103 (5) 104 (5)
  Fever 103 (5) 108 (5)
  Nervousness 102 (5) 87 (4)

Serious, non-bleeding adverse events were experienced in 2% of 2161 Angiomax (bivalirudin) -treated patients and 2% of 2151 heparin-treated patients. The following individual serious non-bleeding adverse events were rare ( > 0.1% to < 1%) and similar in incidence between Angiomax (bivalirudin) - and heparin-treated patients. These events are listed by body system: Body as a Whole: fever, infection, sepsis; Cardiovascular: hypotension, syncope, vascular anomaly, ventricular fibrillation; Nervous: cerebral ischemia, confusion, facial paralysis; Respiratory: lung edema; Urogenital: kidney failure, oliguria. In the BAT trial, there was no causality assessment for adverse events.

Immunogenicity/Re-Exposure

In in vitro studies, Angiomax (bivalirudin) exhibited no platelet aggregation response against sera from patients with a history of HIT/HITTS.

Among 494 subjects who received Angiomax (bivalirudin) in clinical trials and were tested for antibodies, 2 subjects had treatment-emergent positive bivalirudin antibody tests. Neither subject demonstrated clinical evidence of allergic or anaphylactic reactions and repeat testing was not performed. Nine additional patients who had initial positive tests were negative on repeat testing.

Postmarketing Experience

Because postmarketing adverse reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

The following adverse reactions have been identified during postapproval use of Angiomax (bivalirudin) : fatal bleeding; hypersensitivity and allergic reactions including reports of anaphylaxis; lack of anticoagulant effect; thrombus formation during PCI with and without intracoronary brachytherapy, including reports of fatal outcomes.

Read the Angiomax (bivalirudin) Side Effects Center for a complete guide to possible side effects »

DRUG INTERACTIONS

In clinical trials in patients undergoing PCI/PTCA, co-administration of Angiomax (bivalirudin) with heparin, warfarin, thrombolytics, or GPIs was associated with increased risks of major bleeding events compared to patients not receiving these concomitant medications.

There is no experience with co-administration of Angiomax (bivalirudin) and plasma expanders such as dextran.

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

WARNINGS

Included as part of the PRECAUTIONS section.

PRECAUTIONS

Bleeding Events

Although most bleeding associated with the use of Angiomax (bivalirudin) in PCI/PTCA occurs at the site of arterial puncture, hemorrhage can occur at any site. An unexplained fall in blood pressure or hematocrit should lead to serious consideration of a hemorrhagic event and cessation of Angiomax administration [see ADVERSE REACTIONS]. Angiomax (bivalirudin) should be used with caution in patients with disease states associated with an increased risk of bleeding.

Coronary Artery Brachytherapy

An increased risk of thrombus formation, including fatal outcomes, has been associated with the use of Angiomax (bivalirudin) in gamma brachytherapy.

If a decision is made to use Angiomax (bivalirudin) during brachytherapy procedures, maintain meticulous catheter technique, with frequent aspiration and flushing, paying special attention to minimizing conditions of stasis within the catheter or vessels [see ADVERSE REACTIONS].

Carcinogenesis, Mutagenesis, Impairment of Fertility

No long-term studies in animals have been performed to evaluate the carcinogenic potential of Angiomax (bivalirudin) . Angiomax (bivalirudin) displayed no genotoxic potential in the in vitro bacterial cell reverse mutation assay (Ames test), the in vitro Chinese hamster ovary cell forward gene mutation test (CHO/HGPRT), the in vitro human lymphocyte chromosomal aberration assay, the in vitro rat hepatocyte unscheduled DNA synthesis (UDS) assay, and the in vivo rat micronucleus assay. Fertility and general reproductive performance in rats were unaffected by subcutaneous doses of Angiomax (bivalirudin) up to 150 mg/kg/day, about 1.6 times the dose on a body surface area basis (mg/m²) of a 50 kg person given the maximum recommended dose of 15 mg/kg/day.

Use In Specific Populations

Pregnancy

Pregnancy Category B

Reproductive studies have been performed in rats at subcutaneous doses up to 150 mg/kg/day, (1.6 times the maximum recommended human dose based on body surface area) and rabbits at subcutaneous doses up to 150 mg/kg/day (3.2 times the maximum recommended human dose based on body surface area). These studies revealed no evidence of impaired fertility or harm to the fetus attributable to Angiomax (bivalirudin) . There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

Angiomax (bivalirudin) is intended for use with aspirin [see INDICATIONS AND USAGE]. Because of possible adverse effects on the neonate and the potential for increased maternal bleeding, particularly during the third trimester, Angiomax (bivalirudin) and aspirin should be used together during pregnancy only if clearly needed.

Nursing Mothers

It is not known whether bivalirudin is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Angiomax (bivalirudin) is administered to a nursing woman.

Pediatric Use

The safety and effectiveness of Angiomax (bivalirudin) in pediatric patients have not been established.

Geriatric Use

In studies of patients undergoing PCI, 44% were ≥ 65 years of age and 12% of patients were ≥ 75 years old. Elderly patients experienced more bleeding events than younger patients. Patients treated with Angiomax (bivalirudin) experienced fewer bleeding events in each age stratum, compared to heparin.

Renal Impairment

The disposition of Angiomax (bivalirudin) was studied in PTCA patients with mild, moderate and severe renal impairment. The clearance of Angiomax (bivalirudin) was reduced approximately 20% in patients with moderate and severe renal impairment and was reduced approximately 80% in dialysis-dependent patients. [see CLINICAL PHARMACOLOGY].

The infusion dose of Angiomax (bivalirudin) may need to be reduced, and anticoagulant status monitored in patients with renal impairment [see DOSAGE AND ADMINISTRATION].

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

OVERDOSE

Single bolus doses of Angiomax (bivalirudin) up to 7.5 mg/kg have been reported without associated bleeding or other adverse reactions. In cases of overdosage, treatment with Angiomax (bivalirudin) should be immediately discontinued and the patient monitored closely for signs of bleeding. Angiomax is hemodialyzable [see CLINICAL PHARMACOLOGY]. There is no known antidote to Angiomax (bivalirudin) .

CONTRAINDICATIONS

Angiomax (bivalirudin) is contraindicated in patients with:

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

CLINICAL PHARMACOLOGY

Mechanism of Action

Angiomax (bivalirudin) directly inhibits thrombin by specifically binding both to the catalytic site and to the anion-binding exosite of circulating and clot-bound thrombin. Thrombin is a serine proteinase that plays a central role in the thrombotic process, acting to cleave fibrinogen into fibrin monomers and to activate Factor XIII to Factor XIIIa, allowing fibrin to develop a covalently cross-linked framework which stabilizes the thrombus; thrombin also activates Factors V and VIII, promoting further thrombin generation, and activates platelets, stimulating aggregation and granule release. The binding of Angiomax (bivalirudin) to thrombin is reversible as thrombin slowly cleaves the Angiomax (bivalirudin) -Arg3-Pro4 bond, resulting in recovery of thrombin active site functions.

In in vitro studies, Angiomax (bivalirudin) inhibited both soluble (free) and clot-bound thrombin, was not neutralized by products of the platelet release reaction, and prolonged the activated partial thromboplastin time (aPTT), thrombin time (TT), and prothrombin time (PT) of normal human plasma in a concentration-dependent manner. The clinical relevance of these findings is unknown.

Pharmacodynamics

In healthy volunteers and patients (with ≥ 70% vessel occlusion undergoing routine PTCA), Angiomax (bivalirudin) exhibited dose- and concentration-dependent anticoagulant activity as evidenced by prolongation of the ACT, aPTT, PT, and TT. Intravenous administration of Angiomax (bivalirudin) produces an immediate anticoagulant effect. Coagulation times return to baseline approximately 1 hour following cessation of Angiomax (bivalirudin) administration.

In 291 patients with ≥ 70% vessel occlusion undergoing routine PTCA , a positive correlation was observed between the dose of Angiomax (bivalirudin) and the proportion of patients achieving ACT values of 300 sec or 350 sec. At an Angiomax (bivalirudin) dose of 1 mg/kg IV bolus plus 2.5 mg/kg/h IV infusion for 4 hours, followed by 0.2 mg/kg/h, all patients reached maximal ACT values > 300 sec.

Pharmacokinetics

Angiomax (bivalirudin) exhibits linear pharmacokinetics following IV administration to patients undergoing PTCA. In these patients, a mean steady state Angiomax (bivalirudin) concentration of 12.3 ± 1.7 mcg/mL is achieved following an IV bolus of 1 mg/kg and a 4-hour 2.5 mg/kg/h IV infusion. Angiomax (bivalirudin) does not bind to plasma proteins (other than thrombin) or to red blood cells. Angiomax (bivalirudin) is cleared from plasma by a combination of renal mechanisms and proteolytic cleavage, with a half-life in patients with normal renal function of 25 min.

The disposition of Angiomax (bivalirudin) was studied in PTCA patients with mild, moderate, and severe renal impairment. Drug elimination was related to glomerular filtration rate (GFR). Total body clearance was similar for patients with normal renal function and with mild renal impairment (60-89 mL/min). Clearance was reduced in patients with moderate and severe renal impairment and in dialysis-dependent patients (See Table 6 for pharmacokinetic parameters).

Angiomax (bivalirudin) is hemodialyzable, with approximately 25% cleared by hemodialysis.

Table 6: PK Parameters in Patients with Renal Impairment*

Renal Function (GFR, mL/min) Clearance
(mL/min/kg)
Half-life
(min)
Normal renal function ( ≥ 90 mL/min) 3.4 25
Mild renal impairment (60-89 mL/min) 3.4 22
Moderate renal impairment (30-59 mL/min) 2.7 34
Severe renal impairment (10-29 mL/min) 2.8 57
Dialysis-dependent patients (off dialysis) 1.0 3.5 hours
* The ACT should be monitored in renally-impaired patients

Nonclinical Toxicology

Clinical Studies

PCI/PTCA

Angiomax (bivalirudin) has been evaluated in five randomized, controlled interventional cardiology trials reporting 11,422 patients. Stents were deployed in 6062 of the patients in these trials – mainly in trials performed since 1995. Percutaneous transluminal coronary angioplasty, atherectomy or other procedures were performed in the remaining patients.

REPLACE-2 Trial

This was a randomized, double-blind, multicenter study reporting 6002 (intent-to-treat) patients undergoing PCI. Patients were randomized to treatment with Angiomax (bivalirudin) with the “provisional” use of platelet glycoprotein IIb/IIIa inhibitor (GPI) or heparin plus planned use of GPI. GPIs were added on a “provisional” basis to patients who were randomized to Angiomax (bivalirudin) in the following circumstances:

During the study, one or more of these circumstances occurred in 12.7% of patients in the Angiomax (bivalirudin) with provisional GPI arm. GPIs were administered to 7.2% of patients in the Angiomax (bivalirudin) with provisional GPI arm (62.2% of eligible patients).

Patients ranged in age from 25-95 years (median, 63); weight ranged from 35-199 kg (median 85.5); 74.4% were male and 25.6% were female. Indications for PCI included unstable angina (35% of patients), myocardial infarction within 7 days prior to intervention (8% of patients), stable angina (25%) and positive ischemic stress test (24%). Stents were deployed in 85% of patients. Ninety-nine percent of patients received aspirin and 86% received thienopyridines prior to study treatment.

Angiomax (bivalirudin) was administered as a 0.75 mg/kg bolus followed by a 1.75 mg/kg/h infusion for the duration of the procedure. The activated clotting time (ACT – measured by a Hemochron® device) was measured 5 min after the first bolus of study medication. If the ACT was < 225 seconds, an additional bolus of 0.3 mg/kg was given. At investigator discretion, the infusion could be continued following the procedure for up to 4 hours. The median infusion duration was 44 min. Heparin was administered as a 65 U/kg bolus. The activated clotting time (ACT – measured by a Hemochron® device) was measured 5 min after the first bolus of study medication. If the ACT was < 225 seconds, an additional bolus of 20 units/kg was given. GPIs (either abciximab or eptifibatide) were given according to manufacturers' instructions. Both randomized groups could be given “provisional” treatments during the PCI at investigator discretion, but under double-blind conditions. “Provisional” treatment with GPI was requested in 5.2% of patients randomized to heparin plus GPI (they were given placebo) and 7.2% patients randomized to Angiomax (bivalirudin) with provisional GPI (they were given abciximab or eptifibatide according to pre-randomization investigator choice and patient stratification).

The percent of patients reaching protocol-specified levels of anticoagulation was greater in the Angiomax (bivalirudin) with provisional GPI group than in the heparin plus GPI group. For patients randomized to Angiomax (bivalirudin) with provisional GPI, the median 5 min ACT was 358 sec (interquartile range 320-400 sec) and the ACT was < 225 sec in 3%. For patients randomized to heparin plus GPI, the median 5 min ACT was 317 sec (interquartile range 263-373 sec) and the ACT was < 225 sec in 12%. At the end of the procedure, median ACT values were 334 sec (Angiomax (bivalirudin) group) and 276 sec (heparin plus GPI group).

For the composite endpoint of death, MI, or urgent revascularization adjudicated under double-blind conditions, the frequency was higher (7.6%)(95% confidence interval 6.7%-8.6%) in the Angiomax (bivalirudin) with “provisional” GPI arm when compared to the heparin plus GPI arm (7.1%)(95% confidence interval 6.1%-8.0%). However, major hemorrhage was reported significantly less frequently in the Angiomax (bivalirudin) with provisional GPI arm (2.4%) compared to the heparin plus GPI arm (4.1%). Study outcomes are shown in Table 7

Table 7 : Incidences of Clinical Endpoints at 30 Days for REPLACE-2, a Randomized Double-blind Clinical Trial

Intent-to-treat Population ANGIOMAX (bivalirudin) with
“Provisional”
GP In=2994
HEPARIN + GP
In=3008
Efficacy Endpoints
Death, MI, or urgent 7.6% 7.1%
revascularization    
  Death 0.2% 0.4%
  MI 7.0% 6.2%
  Urgent revascularization 1.2% 1.4%
Safety Endpoint
Major hemorrhage*† 2.4% 4.1%
*Defined as intracranial bleeding, retroperitoneal bleeding, a transfusion of > 2 units of blood/blood products, a fall in Hgb > 4 g/dL, whether or not bleeding site is identified, spontaneous or non-spontaneous blood loss with a decrease in Hgb > 3 g/dL.
†p-value < 0.001 between groups.

At 12 months' follow-up, mortality was 1.9% among patients randomized to Angiomax (bivalirudin) with “provisional” GPIs and 2.5% among patients randomized to heparin plus GPI.

Bivalirudin Angioplasty Trial (BAT)

Angiomax (bivalirudin) was evaluated in patients with unstable angina undergoing PTCA in two randomized, double-blind, multicenter studies with identical protocols. Patients must have had unstable angina defined as: (1) a new onset of severe or accelerated angina or rest pain within the month prior to study entry or (2) angina or ischemic rest pain which developed between four hours and two weeks after an acute myocardial infarction (MI). Overall, 4312 patients with unstable angina, including 741 (17%) patients with post-MI angina, were treated in a 1:1 randomized fashion with Angiomax (bivalirudin) or heparin. Patients ranged in age from 29-90 (median 63) years, their weight was a median of 80 kg (39-120 kg), 68% were male, and 91% were Caucasian. Twenty-three percent of patients were treated with heparin within one hour prior to randomization. All patients were administered aspirin 300-325 mg prior to PTCA and daily thereafter. Patients randomized to Angiomax (bivalirudin) were started on an intravenous infusion of Angiomax (bivalirudin) (2.5 mg/kg/h). Within 5 min after starting the infusion, and prior to PTCA, a 1 mg/kg loading dose was administered as an intravenous bolus. The infusion was continued for 4 hours, then the infusion was changed under double-blinded conditions to Angiomax (bivalirudin) (0.2 mg/kg/h) for up to an additional 20 hours (patients received this infusion for an average of 14 hours). The ACT was checked at 5 min and at 45 min following commencement. If on either occasion the ACT was < 350 sec, an additional double-blinded bolus of placebo was administered. The Angiomax (bivalirudin) dose was not titrated to ACT. Median ACT values were: ACT in sec (5th percentile-95th percentile): 345 sec (240-595 sec) at 5 min and 346 sec (range 269-583 sec) at 45 min after initiation of dosing. Patients randomized to heparin were given a loading dose (175 IU/kg) as an intravenous bolus 5 min before the planned procedure, with immediate commencement of an infusion of heparin (15 IU/kg/h). The infusion was continued for 4 hours. After 4 hours of infusion, the heparin infusion was changed under double-blinded conditions to heparin (15 IU/kg/h) for up to 20 additional hours. The ACT was checked at 5 min and at 45 min following commencement. If on either occasion the ACT was < 350 sec, an additional double-blind bolus of heparin (60 IU/kg) was administered. Once the target ACT was achieved for heparin patients, no further ACT measurements were performed. All ACTs were determined with the Hemochron® device. The protocol allowed use of open-label heparin at the discretion of the investigator after discontinuation of blinded study medication, whether or not an endpoint event (procedural failure) had occurred. The use of open-label heparin was similar between Angiomax (bivalirudin) and heparin treatment groups (about 20% in both groups).

The studies were designed to demonstrate the safety and efficacy of Angiomax (bivalirudin) in patients undergoing PTCA as a treatment for unstable angina as compared with a control group of similar patients receiving heparin during and up to 24 hours after initiation of PTCA. The primary protocol endpoint was a composite endpoint called procedural failure, which included both clinical and angiographic elements measured during hospitalization. The clinical elements were: the occurrence of death, MI, or urgent revascularization, adjudicated under double-blind conditions. The angiographic elements were: impending or abrupt vessel closure. The protocol-specified safety endpoint was major hemorrhage.

The median duration of hospitalization was 4 days for both the Angiomax (bivalirudin) and the heparin treatment groups. The rates of procedural failure were similar in the Angiomax (bivalirudin) and heparin treatment groups. Study outcomes are shown in Table 8

Table 8 : Incidences of In-hospital Clinical Endpoints in BAT Trial Occurring within 7 Days

All Patients ANGIOMAX
n=2161
HEPARIN
n=2151
Efficacy Endpoints
Procedural failure* 7.9% 9.3%
Death, MI, revascularization 6.2% 7.9%
  Death 0.2% 0.2%
  MI† 3.3% 4.2%
  Revascularization‡ 4.2% 5.6%
Safety Endpoint
Major hemorrhage§ 3.5% 9.3%
* The protocol-specified primary endpoint (a composite of death or MI or clinical deterioration of cardiac origin requiring revascularization or placement of an aortic balloon pump or angiographic evidence of abrupt vessel closure).
† Defined as: Q-wave MI; CK-MB elevation ≥ 2 x ULN, new ST-or T-wave abnormality, and chest pain ≥ 30 min; OR new LBBB with chest pain ≥ 30 min and/or elevated CK-MB enzymes; OR elevated CK-MB and new ST- or T-wave abnormality without chest pain; OR elevated CK-MB.
‡ Defined as: any revascularization procedure, including angioplasty, CABG, stenting, or placement of an intra-aortic balloon pump.
§ Defined as the occurrence of any of the following: intracranial bleeding, retroperitoneal bleeding, clinically overt bleeding with a decrease in Hgb ≥ 3 g/dL or leading to a transfusion of ≥ 2 units of blood.

AT-BAT Trial

This was a single-group open-label study which enrolled 51 patients with heparin-induced thrombocytopenia (HIT) or heparin induced thrombocytopenia and thrombosis syndrome (HITTS) undergoing PCI. Evidence for the diagnosis of HIT/HITTS was based on a clinical history of a decrease of platelets in patients after heparin administration [new diagnosis or history of clinically suspected or objectively documented HIT/HITTS defined as either: 1) HIT: positive heparin-induced platelet aggregation (HIPA) or other functional assay where the platelet count has decreased to < 100,000/mL (minimum 30% from prior to heparin), or has decreased to < 150,000/mL (minimum 40% from prior to heparin), or has decreased as above within hours of receiving heparin in a patient with a recent, previous exposure to heparin; 2) HITTS: thrombocytopenia as above plus arterial or venous thrombosis diagnosed by physician examination/laboratory and/or appropriate imaging studies]. Patients ranged in age from 48-89 years (median 70); weight ranged from 42-123 kg (median 76); 50% were male and 50% were female. Angiomax (bivalirudin) was administered as either 1 mg/kg bolus followed by 2.5 mg/kg/h (high dose in 28 patients) or 0.75 mg/kg bolus followed by a 1.75 mg/kg/h infusion (lower dose in 25 patients) for up to 4 hours. Ninety-eight percent of patients received aspirin, 86% received clopidogrel and 19% received GPIs.

The median ACT values at the time of device activation were 379 sec (high dose) and 317 sec (lower dose). Following the procedure, 48 of the 51 patients (94%) had TIMI grade 3 flow and stenosis < 50%. One patient died during a bradycardic episode 46 hours after successful PCI, another patient required surgical revascularization, and one patient experienced no flow requiring a temporary intra-aortic balloon.

Two of the fifty-one patients with the diagnosis of HIT/HITTS developed thrombocytopenia after receiving Angiomax (bivalirudin) and GPIs.

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

PATIENT INFORMATION

Advise patients to watch carefully for any signs of bleeding or bruising and to report these to their health care provider when they occur.

Advise patients to discuss with their health care provider their use of any other medications, including over-the-counter medications or herbal products, prior to Angiomax (bivalirudin) use. Examples of other medications that should not be taken with Angiomax (bivalirudin) are warfarin and heparin.

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

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PATIENT INFORMATION

Advise patients to watch carefully for any signs of bleeding or bruising and to report these to their health care provider when they occur.

Advise patients to discuss with their health care provider their use of any other medications, including over-the-counter medications or herbal products, prior to Angiomax (bivalirudin) use. Examples of other medications that should not be taken with Angiomax (bivalirudin) are warfarin and heparin.

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

ANGIOMAX®
(bivalirudin) for Injection, for Intravenous Use

DRUG DESCRIPTION

Angiomax (bivalirudin) is a specific and reversible direct thrombin inhibitor. The active substance is a synthetic, 20 amino acid peptide. The chemical name is D-phenylalanyl-L-prolyl-L-arginyl-L-prolyl-glycylglycyl-glycyl-glycyl-L-asparagyl-glycyl-L-aspartyl-L-phenylalanyl-L-glutamyl-L-glutamyl-L-isoleucyl-L-prolyl-L-glutamyl-L-glutamyl-L-tyrosyl-L-leucine trifluoroacetate (salt) hydrate (Figure 1). The molecular weight of Angiomax (bivalirudin) is 2180 daltons (anhydrous free base peptide).

Angiomax (bivalirudin) is supplied in single-use vials as a white lyophilized cake, which is sterile. Each vial contains 250 mg bivalirudin, 125 mg mannitol, and sodium hydroxide to adjust the pH to 5-6 (equivalent of approximately 12.5 mg sodium). When reconstituted with Sterile Water for Injection, the product yields a clear to opalescent, colorless to slightly yellow solution, pH 5-6.

Figure 1. Structural Formula for Bivalirudin

ANGIOMAX® (bivalirudin) Structural Formula Illustration

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

ANGIOMAX®
(bivalirudin) for Injection, for Intravenous Use

DRUG DESCRIPTION

Angiomax (bivalirudin) is a specific and reversible direct thrombin inhibitor. The active substance is a synthetic, 20 amino acid peptide. The chemical name is D-phenylalanyl-L-prolyl-L-arginyl-L-prolyl-glycylglycyl-glycyl-glycyl-L-asparagyl-glycyl-L-aspartyl-L-phenylalanyl-L-glutamyl-L-glutamyl-L-isoleucyl-L-prolyl-L-glutamyl-L-glutamyl-L-tyrosyl-L-leucine trifluoroacetate (salt) hydrate (Figure 1). The molecular weight of Angiomax (bivalirudin) is 2180 daltons (anhydrous free base peptide).

Angiomax (bivalirudin) is supplied in single-use vials as a white lyophilized cake, which is sterile. Each vial contains 250 mg bivalirudin, 125 mg mannitol, and sodium hydroxide to adjust the pH to 5-6 (equivalent of approximately 12.5 mg sodium). When reconstituted with Sterile Water for Injection, the product yields a clear to opalescent, colorless to slightly yellow solution, pH 5-6.

Figure 1. Structural Formula for Bivalirudin

ANGIOMAX® (bivalirudin) Structural Formula Illustration

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

ANGIOMAX®
(bivalirudin) for Injection, for Intravenous Use

DRUG DESCRIPTION

Angiomax (bivalirudin) is a specific and reversible direct thrombin inhibitor. The active substance is a synthetic, 20 amino acid peptide. The chemical name is D-phenylalanyl-L-prolyl-L-arginyl-L-prolyl-glycylglycyl-glycyl-glycyl-L-asparagyl-glycyl-L-aspartyl-L-phenylalanyl-L-glutamyl-L-glutamyl-L-isoleucyl-L-prolyl-L-glutamyl-L-glutamyl-L-tyrosyl-L-leucine trifluoroacetate (salt) hydrate (Figure 1). The molecular weight of Angiomax (bivalirudin) is 2180 daltons (anhydrous free base peptide).

Angiomax (bivalirudin) is supplied in single-use vials as a white lyophilized cake, which is sterile. Each vial contains 250 mg bivalirudin, 125 mg mannitol, and sodium hydroxide to adjust the pH to 5-6 (equivalent of approximately 12.5 mg sodium). When reconstituted with Sterile Water for Injection, the product yields a clear to opalescent, colorless to slightly yellow solution, pH 5-6.

Figure 1. Structural Formula for Bivalirudin

ANGIOMAX® (bivalirudin) Structural Formula Illustration

Last reviewed on RxList: 7/20/2010
This monograph has been modified to include the generic and brand name in many instances.

Angiomax Patient Information Including Side Effects

Brand Names: Angiomax

Generic Name: bivalirudin (Pronunciation: bye VAL i roo din)

What is bivalirudin (Angiomax)?

Bivalirudin keeps the platelets in your blood from coagulating (clotting) to prevent unwanted blood clots that can occur with certain heart or blood vessel conditions.

Bivalirudin is used to prevent blood clots in people with severe chest pain or other conditions who are undergoing a procedure called angioplasty (to open blocked arteries).

Bivalirudin may also be used for purposes other than those listed in this medication guide.

What are the possible side effects of bivalirudin (Angiomax)?

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Call your doctor at once if you have any of these serious side effects:

  • sudden numbness or weakness, especially on one side of the body;
  • sudden headache, confusion, problems with vision, speech, or balance;
  • pain or swelling in one or both legs;
  • any bleeding that will not stop;
  • black, bloody, or tarry stools;
  • coughing up blood or vomit that looks like coffee grounds;
  • slow heart rate;
  • increased blood pressure (severe headache, blurred vision, trouble concentrating, chest pain, numbness, seizure);
  • decreased blood pressure (feeling light-headed or fainting); or
  • urinating less than usual or not at all.

Less serious side effects are more likely to occur, such as:

  • pain in your back or pelvis;
  • nausea, vomiting, stomach pain or upset;
  • feeling restless or nervous;
  • headache;
  • fever;
  • sleep problems (insomnia);
  • pain, bleeding, or irritation where the injection was given.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome. You may report side effects to FDA at 1-800-FDA-1088.

Read the Angiomax (bivalirudin) Side Effects Center for a complete guide to possible side effects »

What is the most important information I should know about bivalirudin (Angiomax)?

Do not use this medication if you are allergic to bivalirudin, or if you have any major bleeding from a surgery, injury, or other medical trauma.

Bivalirudin is not expected to be harmful to an unborn baby. However, aspirin is usually given with bivalirudin, and aspirin can cause bleeding when it is taken during the last 3 months of pregnancy. Aspirin can also cause side effects in a newborn baby.

Tell your doctor if you are pregnant or plan to become pregnant during treatment with bivalirudin and aspirin.

Before using bivalirudin, tell your doctor if you are allergic to any drugs, or if you have heart disease, kidney disease, or a bleeding or blood clotting disorder such as hemophilia.

Tell your doctor if you are using or receiving blood thinners or any other medications used to prevent blood clots, such as alteplase (Activase), anistreplase (Eminase), clopidogrel (Plavix), dipyridamole (Persantine), streptokinase (Kabikinase, Streptase), ticlopidine (Ticlid), or urokinase (Abbokinase).

Because bivalirudin keeps your blood from coagulating (clotting) to prevent unwanted blood clots, it can also make it easier for you to bleed, even from a minor injury. Contact your doctor or seek emergency medical attention if you have bleeding that will not stop.

Side Effects Centers

Angiomax Patient Information including How Should I Take

What should I discuss with my health care provider before taking bivalirudin (Angiomax)?

Do not use this medication if you are allergic to bivalirudin, or if you have any major bleeding from a surgery, injury, or other medical trauma.

Before using bivalirudin, tell your doctor if you are allergic to any drugs, or if you have:

  • heart disease;
  • kidney disease; or
  • a bleeding or blood clotting disorder (such as hemophilia).

If you have any of these conditions, you may not be able to use bivalirudin, or you may need dosage adjustments or special tests during treatment.

FDA pregnancy category B. This medication is not expected to be harmful to an unborn baby. However, aspirin is usually given with bivalirudin, and aspirin can cause bleeding when it is taken during the last 3 months of pregnancy. Aspirin can also cause side effects in a newborn baby.

Tell your doctor if you are pregnant or plan to become pregnant during treatment with bivalirudin and aspirin.

It is not known whether bivalirudin passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.

How should I take bivalirudin (Angiomax)?

Bivalirudin is given as an injection through a needle placed into a vein. You will receive this injection during your angioplasty procedure in a clinic or hospital setting. The medicine must be given throughout the entire procedure.

Bivalirudin is usually given together with aspirin.

Because bivalirudin keeps your blood from coagulating (clotting) to prevent unwanted blood clots, it can also make it easier for you to bleed, even from a minor injury. Contact your doctor or seek emergency medical attention if you have bleeding that will not stop.

Side Effects Centers

Angiomax Patient Information including If I Miss a Dose

What happens if I miss a dose (Angiomax)?

Since bivalirudin is usually given in a hospital or clinic setting as needed, it is not likely that you will miss a dose.

What happens if I overdose (Angiomax)?

Seek emergency medical attention if you think you have used too much of this medicine.

Symptoms of a bivalirudin overdose are not known.

What should I avoid while taking bivalirudin (Angiomax)?

Bivalirudin lowers blood cells that help your blood clot. This can make it easier for you to bruise or bleed from an injury or minor cut. Avoid activities that increase your risk of a bruising or bleeding injury. Use extra caution to avoid cuts when brushing your teeth or shaving.

Avoid drinking alcohol while taking bivaluridin. Alcohol may increase your risk of bleeding in your stomach or intestines.

What other drugs will affect bivalirudin (Angiomax)?

Before receiving bivalirudin, tell your doctor if you are using or receiving any of the following drugs:

  • a blood thinner such as warfarin (Coumadin), heparin, ardeparin (Normiflo), dalteparin (Fragmin), danaparoid (Orgaran), enoxaparin (Lovenox), or tinzaparin (Innohep); or
  • any other medications used to prevent blood clots, such as alteplase (Activase), anistreplase (Eminase), clopidogrel (Plavix), dipyridamole (Persantine), streptokinase (Kabikinase, Streptase), ticlopidine (Ticlid), or urokinase (Abbokinase).

If you are using any of these drugs, you may not be able to use bivalirudin, or you may need dosage adjustments or special tests during treatment.

There may be other drugs not listed that can affect bivalirudin. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.

Where can I get more information?

Your pharmacist has information about bivalirudin written for health professionals that you may read.


Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist.

Copyright 1996-2012 Cerner Multum, Inc. Version: 1.05. Revision date: 12/15/2010.

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