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Direct Thrombin Inhibitors (Argatroban, Dabigatran, Bivalirudin)

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Summary

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Key Points

  • Direct Thrombin Inhibitors (DTIs)
    • Drug Names
      • Bivalirudin, lepirudin, hirudin (-rudin ending)
      • Argatroban
      • Dabigatran
    • Mechanism
      • Directly blocks thrombin (Factor IIa) binding
        • Binds to free and clot-associated thrombin
        • Prolongs thrombin time (TT)
        • Prevents formation of clots (secondary hemostasis)
      • Administered orally (dabigatran) or IV (bivalirudin, argatroban)
    • Clinical Use
      • Heparin-induced thrombocytopenia (HIT)
        • Argatroban (parenteral) and lepirudin are primarily used for management of heparin-induced thrombocytopenia.
        • Majorly high-yield (!!!!): you will see a question about this on test day.
      • DVT (Venous thromboembolism/VTE) prophylaxis and atrial fibrillation
        • Dabigatran (oral) is used for DVT prevention and treatment and for stroke prevention in atrial fibrillation.
    • Laboratory Findings
      • No change in PT/PTT
      • Do not require routine lab monitoring
        • Allows dabigatran to be used for long-term oral anticoagulation
    • Reversal
      • Dabigatran: Idarucizumab (monoclonal antibody)
        • This is relatively new - not high-yield yet
      • No reversal agents for argatroban/bivalirudin
        • If life-threatening bleeding, give prothrombin complex concentrate (PCC), which contains factors II (thrombin), IX, and X