Bivalirudin dosing during prolonged intermittent renal replacement therapy: a case report
- PDF / 813,503 Bytes
- 5 Pages / 595.276 x 790.866 pts Page_size
- 49 Downloads / 234 Views
Bivalirudin dosing during prolonged intermittent renal replacement therapy: a case report Nicole M. Bohm1 · Chase Brown1 Accepted: 5 October 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract As patients transition between dialysis modalities, and from the intra- to the inter-dialytic period, medications with a narrow therapeutic index that are cleared in dialysis may require dose adjustments and close monitoring. Three cases of patients receiving bivalirudin while converting from continuous to prolonged intermittent renal replacement therapy are reported. Details provided include flow rates and ultrafiltrate volume. In these cases, it appears pre-emptive dose adjustments may be unwarranted, and clinicians should be aware of potential rebound after cessation of dialysis. Keywords Bivalirudin · Prolonged intermittent renal replacement therapy · Dialysis
Highlights • Patients transitioning from continuous to prolonged
intermittent renal replacement therapy may have similar bivalirudin dosing requirements. • aPTTs appear to trend down during prolonged intermittent renal replacement therapy and rebound shortly after the dialysis session is complete.
Background Limited data are available to guide medication dosing for patients receiving prolonged intermittent renal replacement therapy (PIRRT), particularly as patients shift from on- to off-dialysis or advance from continuous to intermittent renal replacement therapy [1]. For narrow therapeutic index medications such as anticoagulants, it is critical to anticipate how dosing requirements fluctuate during these intra- vs interdialytic periods. Bivalirudin is a direct thrombin inhibitor that may require lower doses to reach therapeutic targets in patients receiving renal replacement therapy [2]. While a * Nicole M. Bohm [email protected] 1
Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
small number of cases have been reported, there is no data available demonstrating shifts in aPTT or dosing requirements during transition periods.
Case report 3 patients anticoagulated with bivalirudin at a stable dose on continuous renal replacement therapy (CRRT) were transitioned to PIRRT using NxStage System One (NxStage Medical, Lawrence, MA) in venovenous hemodialysis modality (CVVHD). The NxStage Acute Care Cartridge with a Purema H Filter (1.6 m2 surface area high efficiency polyethersulfone membrane) was used. Bivalirudin was titrated to activated partial thromboplastin time (aPTT) of 50–80 s for the first 2 patients and 60–80 s for patient 3. Due to the unique circumstances of these patients, they were excluded from the institutional direct thrombin inhibitor protocol; instead, anticoagulation was managed collaboratively by the on-call pharmacist and primary team. Figure 1 provides an overview of aPTT results and bivalirudin dosing in all 3 patients. Patient 1 A 35-year-old man was admitted after cardiac arrest. His hospital course was complicated by pulmonary embolism
Data Loading...
