Bivalirudin (Angiomax, Angiox)


Anticoagulation During Extracorporeal Life Support (ECLS)

Anticoagulation During Percutaneous Coronary Intervention (PCI) (see Percutaneous Coronary Intervention)

General Comments

  • Use During Percutaneous Coronary Intervention (PCI) was the First FDA-Approved for Bivalirudin (Thromb Haemost, 2008) [MEDLINE]

Clinical Efficacy


Heparin-Induced Thrombocytopenia (HIT) (see Heparin-Induced Thrombocytopenia)

Clinical Efficacy

  • Systematic Review and Meta-Analysis of the Safety/Efficacy of Anticoagulants in the Treatment of Heparin-Induced Thrombocytopenia (Am J Hematol, 2021) [MEDLINE]: n = 4,698 (from 92 studies)
    • The Pooled Rate of Platelet Recovery Ranged from 74% (Bivalirudin) to 99% (Fondaparinux)
    • The Pooled Rate of Thromboembolism Ranged from from 1% (Fondaparinux) to 7% (Danaparoid)
    • The Pooled Rate of Major Bleeding Ranged from 1% (DOAC) to 14% (Bivalirudin)
    • The Pooled Rate of Death Ranged from 7% (Fondaparinux) to 19% (Bivalirudin)
    • Confidence Intervals were Mostly Overlapping, and Results were Not Influenced by Patient Population, Diagnostic Test Used, Study Design, or Type of Article
    • Safety and Efficacy Outcomes were Similar Among the Anticoagulants, and Significant Factors Affecting These Outcomes were Not Identified
    • Findings Support Fondaparinux and DOAC’s as Viable Alternatives to Conventional Anticoagulants for the Treatment of Acute Heparin-Induced Thrombocytopenia

Percutaneous Coronary Intervention (PCI) (see Percutaneous Coronary Intervention)


Bivalirudin is a Thrombin Inhibitor (see Factor IIa Inhibitors)

  • Affinity for Thrombin is Intermediate Between that of Lepirudin (Which Has the Highest for Thrombin) and Argatroban (Which Has the Lowest Affinity got Thrombin) (Thromb Haemost, 2008) [MEDLINE]
    • This Explains Why Bivalirudin Interferes with Functional Clotting Assays to an Extent Intermediate Between that Achieved by Lepirudin and Argatroban
      • This effect is best known for the PT (INR)
        • Higher Affinity for Thrombin Corresponds to Lower Molar Direct Thrombin Inhibitor Requirements to Prolong the aPTT
        • In Turn, Lower Concentrations Required for aPTT Prolongation (and, Presumably, In Vivo Effect) Result in Decreased INR Prolongation


  • Predominantly Non-Organ Elimination (Proteolysis)
  • Half-Life: 25 min


Intravenous (IV)

Dose Adjustment

Use in Pregnancy (see Pregnancy)

Use During Breast Feeding

Adverse Effects

Hemorrhagic Adverse Effects

Other Adverse Effects


  • xxx