Cangrelor: Drug information

For additional information see "Cangrelor: Patient drug information"

For abbreviations, symbols, and age group definitions show table

Brand Names: US

Kengreal

Brand Names: Canada

Kengrexal

Pharmacologic Category

Antiplatelet Agent;
Antiplatelet Agent, Non-thienopyridine;
P2Y12 Antagonist

Dosing: Adult

Percutaneous coronary intervention

Percutaneous coronary intervention: IV: 30 mcg/kg bolus prior to percutaneous coronary intervention (PCI) followed immediately by an infusion of 4 mcg/kg/minute continued for at least 2 hours or for the duration of the PCI, whichever is longer.

Transitioning patients to oral P2Y₁₂ antagonist therapy after percutaneous coronary intervention:

Conversion to clopidogrel: Administer 600 mg of clopidogrel immediately after discontinuing cangrelor infusion. Do not administer clopidogrel prior to cangrelor discontinuation.

Conversion to prasugrel: Administer 60 mg of prasugrel immediately after discontinuing cangrelor infusion. Do not administer prasugrel prior to cangrelor discontinuation.

Conversion to ticagrelor: Administer 180 mg of ticagrelor at any time during cangrelor infusion or immediately after discontinuing cangrelor infusion.

Bridging therapy prior to cardiac surgery

Bridging therapy prior to cardiac surgery (off-label use):

Note: Routine bridging is not recommended. However, exceptions can be made for high-risk patients (eg, coronary stenting in a critical vessel within the past 3 months) (Ref).

IV: 0.75 mcg/kg/min (without a bolus dose) following thienopyridine discontinuation for up to 7 days prior to surgery; discontinue 1 to 6 hours prior to surgical incision based on risk for thrombotic complications after antiplatelet therapy has been withheld. Cangrelor half-life is ~3 to 6 minutes, so for patients at high risk for thrombotic complications, consider minimizing the time between discontinuation and start of surgery (Ref).

Dosing: Kidney Impairment: Adult

No dosage adjustment necessary

Dosing: Liver Impairment: Adult

No dosage adjustment necessary

Dosing: Older Adult

Refer to adult dosing.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

Hematologic & oncologic: Hemorrhage (GUSTO: 16%; TIMI: <1%)

Renal: Renal insufficiency (3%; severe; creatinine clearance <30 mL/minute)

Respiratory: Dyspnea (1%)

<1%, postmarketing, and/or case reports: Hypersensitivity reaction

Contraindications

Known hypersensitivity (eg, anaphylaxis) to cangrelor or any component of the formulation; significant active bleeding.

Canadian labeling: Additional contraindications (not in US labeling): Patients with increased risk for bleeding; patients who had an ischemic stroke or any previous hemorrhagic stroke.

Warnings/Precautions

Concerns related to adverse effects:

• Bleeding: Similar to other P2Y₁₂ antagonists, the use of cangrelor increases the risk of bleeding; however, due to the short elimination half-life, no antiplatelet effect is observed an hour after discontinuation.

• Hypersensitivity: Although rare, serious cases of hypersensitivity (eg, anaphylaxis, anaphylactic shock, bronchospasm, angioedema, stridor) have been reported with cangrelor.

Concurrent drug therapy issues:

• Thienopyridines: If clopidogrel or prasugrel are administered prior to discontinuation of the cangrelor infusion, no antiplatelet effect will occur until the next dose is administered. Therefore, do not administer until after the cangrelor infusion is discontinued.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous:

Kengreal: 50 mg (1 ea)

Generic Equivalent Available: US

Pricing: US

Solution (reconstituted) (Kengreal Intravenous)

50 mg (per each): $1,201.44

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous:

Kengrexal: 50 mg (1 ea)

Administration: Adult

IV: Vial must be diluted prior to infusion. Administer via a dedicated IV line.

Obtain bolus volume from the prepared bag and administer rapidly over <1 minute via manual IV push or the infusion pump. Ensure the bolus is completely administered before the start of PCI. Start the infusion immediately after administration of the bolus.

Use: Labeled Indications

Percutaneous coronary intervention (PCI): Adjunct to PCI to reduce the risk of periprocedural myocardial infarction, repeat coronary revascularization, and stent thrombosis in patients who have not been treated with a P2Y₁₂ platelet inhibitor and are not being given a glycoprotein IIb/IIIa inhibitor.

Use: Off-Label: Adult

Bridging therapy prior to cardiac surgery

Medication Safety Issues

Sound-alike/look-alike issues:

Cangrelor may be confused with ticagrelor.

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.

Abrocitinib: Therapeutic Antiplatelets may increase antiplatelet effects of Abrocitinib. Management: Do not use antiplatelet drugs with abrocitinib during the first 3 months of abrocitinib therapy. The abrocitinib prescribing information lists this combination as contraindicated. This does not apply to low dose aspirin (81 mg/day or less). Risk X: Avoid

Acalabrutinib: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Aducanumab: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Agents with Antiplatelet Effects: May increase antiplatelet effects of Antiplatelet Agents (P2Y12 Inhibitors). Risk C: Monitor

Anagrelide: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Anticoagulants (Miscellaneous Agents): Therapeutic Antiplatelets may increase anticoagulant effects of Anticoagulants (Miscellaneous Agents). Risk C: Monitor

Antiplatelet Agents (P2Y12 Inhibitors): Therapeutic Antiplatelets may increase antiplatelet effects of Antiplatelet Agents (P2Y12 Inhibitors). Risk C: Monitor

Caplacizumab: May increase antiplatelet effects of Therapeutic Antiplatelets. Management: Avoid this combination if possible. If coadministration is required, monitor closely for bleeding. Interrupt caplacizumab if clinically significant bleeding occurs and administer von Willebrand factor concentrate to rapidly correct hemostasis, if needed. Risk D: Consider Therapy Modification

Clopidogrel: Cangrelor may decrease antiplatelet effects of Clopidogrel. More specifically, while the use of Cangrelor is expected to increase total platelet inhibition in patients who have previously received Clopidogrel, Cangrelor is expected to decrease binding of Clopidogrel metabolites to P2Y12 receptors and thus reduce the extent of irreversible platelet inhibition. Management: Avoid administration of clopidogrel until cangrelor infusion is discontinued. Risk D: Consider Therapy Modification

Collagenase (Systemic): Therapeutic Antiplatelets may increase adverse/toxic effects of Collagenase (Systemic). Specifically, the risk of injection site bruising and or bleeding may be increased. Risk C: Monitor

Dabigatran Etexilate: Antiplatelet Agents (P2Y12 Inhibitors) may increase anticoagulant effects of Dabigatran Etexilate. Risk C: Monitor

Dasatinib: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Deoxycholic Acid: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Desirudin: Therapeutic Antiplatelets may increase anticoagulant effects of Desirudin. Risk C: Monitor

Direct Oral Anticoagulants (DOACs): Antiplatelet Agents (P2Y12 Inhibitors) may increase anticoagulant effects of Direct Oral Anticoagulants (DOACs). Risk C: Monitor

Donanemab: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

FentaNYL: May decrease antiplatelet effects of Antiplatelet Agents (P2Y12 Inhibitors). FentaNYL may decrease serum concentration of Antiplatelet Agents (P2Y12 Inhibitors). Risk C: Monitor

Fondaparinux: Antiplatelet Agents (P2Y12 Inhibitors) may increase anticoagulant effects of Fondaparinux. Management: Discontinue antiplatelet agents, such as P2Y12 inhibitors, prior to fondaparinux therapy, if possible. If co-administration is required use caution and monitor for bleeding. Risk D: Consider Therapy Modification

Glycoprotein IIb/IIIa Inhibitors: Therapeutic Antiplatelets may increase anticoagulant effects of Glycoprotein IIb/IIIa Inhibitors. Risk C: Monitor

Heparin: Antiplatelet Agents (P2Y12 Inhibitors) may increase anticoagulant effects of Heparin. Risk C: Monitor

Heparins (Low Molecular Weight): Antiplatelet Agents (P2Y12 Inhibitors) may increase anticoagulant effects of Heparins (Low Molecular Weight). Risk C: Monitor

Herbal Products with Anticoagulant/Antiplatelet Effects: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Ibritumomab Tiuxetan: Therapeutic Antiplatelets may increase antiplatelet effects of Ibritumomab Tiuxetan. Risk C: Monitor

Ibrutinib: Therapeutic Antiplatelets may increase adverse/toxic effects of Ibrutinib. Specifically, the risks of bleeding and hemorrhage may be increased. Risk C: Monitor

Icosapent Ethyl: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Inotersen: Therapeutic Antiplatelets may increase adverse/toxic effects of Inotersen. Specifically, the risk of bleeding may be increased. Risk C: Monitor

Lecanemab: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Limaprost: May increase adverse/toxic effects of Therapeutic Antiplatelets. Specifically, the risk of bleeding may be increased. Risk C: Monitor

Lipid Emulsion (Fish Oil Based): May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Miscellaneous Antiplatelets: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Multivitamins/Fluoride (with ADE): May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Multivitamins/Minerals (with ADEK, Folate, Iron): May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Multivitamins/Minerals (with AE, No Iron): May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Obinutuzumab: Therapeutic Antiplatelets may increase adverse/toxic effects of Obinutuzumab. Specifically, the risk of bleeding may be increased. Management: Consider avoiding coadministration of obinutuzumab and therapeutic antiplatelets, especially during the first cycle of obinutuzumab therapy. Risk D: Consider Therapy Modification

Omega-3 Fatty Acids: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Pentosan Polysulfate Sodium: Therapeutic Antiplatelets may increase adverse/toxic effects of Pentosan Polysulfate Sodium. Specifically, the risk of hemorrhage may be increased. Risk C: Monitor

Pirtobrutinib: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Prasugrel: Cangrelor may decrease antiplatelet effects of Prasugrel. More specifically, while the use of Cangrelor is expected to increase total platelet inhibition in patients who have previously received Prasugrel, Cangrelor is expected to decrease binding of Prasugrel metabolites to P2Y12 receptors and thus reduce the extent of irreversible platelet inhibition. Management: Avoid administration of prasugrel until cangrelor is discontinued. Risk D: Consider Therapy Modification

Selumetinib: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Therapeutic Antiplatelets: May increase antiplatelet effects of Antiplatelet Agents (P2Y12 Inhibitors). Risk C: Monitor

Thrombolytic Agents: Therapeutic Antiplatelets may increase adverse/toxic effects of Thrombolytic Agents. Specifically, the risk of bleeding may be increased. Risk C: Monitor

Tipranavir: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Vitamin E (Systemic): May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Vitamin K Antagonists: Antiplatelet Agents (P2Y12 Inhibitors) may increase anticoagulant effects of Vitamin K Antagonists. Risk C: Monitor

Volanesorsen: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Zanubrutinib: May increase antiplatelet effects of Therapeutic Antiplatelets. Risk C: Monitor

Pregnancy Considerations

Adverse events were observed in some animal reproduction studies.

Breastfeeding Considerations

It is not known if cangrelor is excreted in breast milk

Monitoring Parameters

Monitor for signs/symptoms of bleeding.

Mechanism of Action

Cangrelor, a nonthienopyridine adenosine triphosphate analogue, is a direct P2Y₁₂ platelet receptor inhibitor that blocks adenosine diphosphate (ADP)-induced platelet activation and aggregation. Cangrelor binds selectively and reversibly to the P2Y₁₂ receptor, preventing further signaling and platelet activation.

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: Platelet inhibition occurs within 2 minutes

Duration of action: Antiplatelet effect is maintained throughout duration of infusion. After discontinuation, platelet function returns to normal within 1 hour

Distribution: Volume of distribution: 3.9 L

Protein binding: ~97% to 98%

Metabolism: Rapidly inactivated in the circulation by dephosphorylation to its primary metabolite, a nucleoside, which has negligible anti-platelet activity

Half-life elimination: ~3 to 6 minutes

Time to peak: Within 2 minutes

Excretion: Urine (58%); feces (35%)

Brand Names: International

International Brand Names by Country

For country code abbreviations (show table)

(AE) United Arab Emirates: Kengrexal;
(AT) Austria: Kengrexal;
(BE) Belgium: Kengrexal;
(CH) Switzerland: Kengrexal;
(CZ) Czech Republic: Kengrexal;
(DE) Germany: Kengrexal;
(ES) Spain: Kengrexal;
(FI) Finland: Kengrexal;
(FR) France: Kengrexal;
(GB) United Kingdom: Kengrexal;
(IN) India: Canreal;
(IT) Italy: Kengrexal;
(NL) Netherlands: Kengrexal;
(NO) Norway: Kengrexal;
(PL) Poland: Kengrexal;
(RO) Romania: Kengrexal;
(SE) Sweden: Kengrexal;
(SI) Slovenia: Kengrexal;
(SK) Slovakia: Kengrexal;
(TR) Turkey: Kengrexal;
(UA) Ukraine: Kengrexal

Akers WS, Oh JJ, Oestreich JH, Ferraris S, Wethington M, Steinhubl SR. Pharmacokinetics and pharmacodynamics of a bolus and infusion of cangrelor: a direct, parenteral P2Y12 receptor antagonist. J Clin Pharmacol. 2010;50(1):27-35. doi: 10.1177/0091270009344986. [PubMed 19779037]
Angiolillo DJ, Firstenberg MS, Price MJ, et al; BRIDGE Investigators. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA. 2012;307(3):265-274 [PubMed 22253393]
Bhatt DL, Lincoff AM, Gibson CM, et al; CHAMPION PLATFORM Investigators. Intravenous platelet blockade with cangrelor during PCI. N Engl J Med. 2009;361(24):2330-2341. doi: 10.1056/NEJMoa0908629. [PubMed 19915222]
Bhatt DL, Stone GW, Mahaffey KW, et al; CHAMPION PHOENIX Investigators. Effect of platelet inhibition with cangrelor during PCI on ischemic events. N Engl J Med. 2013;368(14):1303-1313. doi: 10.1056/NEJMoa1300815. [PubMed 23473369]
Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: an American College of Chest Physicians clinical practice guideline. Chest. 2022;162(5):e207-e243. doi:10.1016/j.chest.2022.07.025 [PubMed 35964704]
Harrington RA, Stone GW, McNulty S, et al. Platelet inhibition with cangrelor in patients undergoing PCI. N Engl J Med. 2009;361(24):2318-2329. doi: 10.1056/NEJMoa0908628. [PubMed 19915221]
Kengreal (cangrelor) [prescribing information]. Cary, NC: Chiesi USA Inc; January 2023.
Kengrexal (cangrelor) [product monograph]. Brantford, Ontario, Canada: Methapharm Inc; January 2023.
Schneider DJ, Agarwal Z, Seecheran N, Keating FK, Gogo P. Pharmacodynamic effects during the transition between cangrelor and ticagrelor. JACC Cardiovasc Interv. 2014;7(4):435-442. doi: 10.1016/j.jcin.2013.08.017. [PubMed 24656538]
Steinhubl SR, Oh JJ, Oestreich JH, Ferraris S, Charnigo R, Akers WS. Transitioning patients from cangrelor to clopidogrel: pharmacodynamic evidence of a competitive effect. Thromb Res. 2008;121(4):527-534. [PubMed 17631948]

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Cangrelor: Drug information