Eptifibatide Heparin

The data for the use of GP Ilb/Illa inhibitors in conjunction with lAT are even more scant, and are limited to case reports. Intravenous abciximab has been successfully used as adjunctive therapy to lA rt-PA or UK in cases of acute stroke. Desh-mukh et al. reported on 21 patients with large vessel occlusion refractory to lAT with rt-PA who were treated with IV and/or lA abciximab, eptifibatide, or tirofiban. Twelve patients also received IV rt-PA and 18 patients underwent balloon angioplasty. Complete or partial recanalization was achieved in 17 of 21 patients. Three patients (14%) had asymptomatic ICH, but there were no cases of symptomatic ICH. Mangiafico et al. described 21 stroke patients treated with an intravenous bolus of tirofiban and heparin followed by lA urokinase. Nineteen of these patients also underwent balloon angioplasty. TIMI 2-3 flow was achieved in 17 of 21 patients. ICH occurred in 5 of 21 patients (3 symptomatic ICH and 2 SAH), and was fatal in 3... 

Wolfram R, Leborgne L, Cheneau E, Pinnow EE, Canos DA, Hellinga D et al. Comparison of effectiveness and safety of three different antithrombotic regimens (bi-valirudin, eptifibatide, and heparin) in preventing myocardial ischemia during percutaneous coronary intervention. Am J Cardiol 2003 92(9) 1080-3. 

Goodman SG, Fitchett D, Armstrong PW, et al. Randomized evaluation of the safety and efficacy of enoxaparin versus unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes receiving the glycoprotein llb/llla inhibitor eptifibatide. Circulation 2003 107 238-244. 

Keating FK, Dauerman HL, Whitaker DA, Sobel BE, Schneider DJ. Increased expression of platelet P-selectin and formation of platelet-leukocyte aggregates in blood from patients treated with unfractionated heparin plus eptifibatide compared with bivalirudin. Thromb Res 2006 I 18 361-369. 

Eptifibatide (Integrelin), a cyclic heptapeptide based on a peptide sequence in snake venom, is a GPIIb/llla inhibitor used in conjunction with heparin and aspirin for the treatment of ACS or in PCI, with or without stenting and clopidogrel (Table I). 

Madan M, Radhakrishnan S, Reis M, et al. Comparison of enoxaparin versus heparin during elective percutaneous coronary intervention performed with either eptifibatide or tirofiban (the ACTION Trial). Am J Cardiol 2005 95(1 I) 1295-1301. 

Case Conclusion Despite treatment with nitroglycerin, metoprolol, and heparin drips in the ED, PB continued to have chest pain. He was scheduled for an emergent coronary catheterization to improve symptoms and prevent further ischemia. He was started on an eptifibatide IV drip for 24 hours and oral clopidogrel for 4 weeks. 

Tirofiban Tiroflban (Aggrastat), a nonpeptide, small-molecule inhibitor of anePs, appears to have a similar mechanism of action as eptifibatide. Tiroflban has a short duration of action and has efficacy in non-Q-wave myocardial infarction and unstable angina. Reductions in death and myocardial infarction have been about 20% compared to placebo, results similar to those with eptifibatide. Side effects also are similar to those of eptifibatide. The agent is specific to anePs and does not react with the vitronectin receptor. Metaanalysis of trials using anePs inhibitors suggests that their value in antiplatelet therapy after acute myocardial infarction is limited. Tiroflban is administered intravenously at an initial rate of 0.4 pg/kg per minute for 30 minutes, and then continued at 0.1 mg/kg per minute for 12 to 24 hours after angioplasty or atherectomy. It is used in conjunction with heparin. 

The UK manufacturer of eptifibatide reports that concurrent use with warfarin and dipyridamole did not appear to increase the risk of major and minor bleeding, and the use of heparin is recommended, but they warn that if eptifibatide is given with heparin, there must be careful monitoring including the aPTT. 

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