Argatroban: Pediatric drug information

For additional information see "Argatroban: Drug information" and "Argatroban: Patient drug information"

For abbreviations, symbols, and age group definitions show table

Therapeutic Category

Anticoagulant, Thrombin Inhibitor

Dosing: Neonatal

Heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia (HIT): Very limited data available: Note: Required maintenance dose is highly variable between patients; frequent dosage adjustments required in critically ill patients and/or patients with liver impairment to maintain desired anticoagulant activity (Ref).

Term Neonates: Continuous IV Infusion:

Initial dose: 0.75 mcg/kg/minute; measure aPTT after 2 hours; titrate to maintain aPTT in desired range; adjust in increments of 0.1 to 0.25 mcg/kg/minute if normal liver function. Note: Effects of liver impairment in neonates are unknown; however, lower doses have been used in infants and children with liver impairment (Ref).

Maintenance dose: Measure aPTT 2 hours after any dose change and at least once daily; more frequent monitoring may be required based on clinical status; adjust dose until the steady-state aPTT is 1.5 to 3 times the initial baseline value (depends on bleeding risk), not exceeding 100 seconds; adjust in increments of 0.1 to 0.25 mcg/kg/minute if normal liver function (Ref).

Anticoagulation, mechanical circulatory support

Anticoagulation, mechanical circulatory support:

Ventricular assist device (VAD) (Ref): Very limited data available:

Note: Dosing based on a consensus protocol; goal aPTT range determined by risk of bleeding and thrombosis and postoperative phase of care.

Neonates: Initial dose: Continuous IV infusion: 0.5 mcg/kg/minute; consider a lower initial dose in the setting of liver impairment with baseline elevated INR; titrate to achieve target aPTT (See "Argatroban Dose Adjustments to Achieve Target aPTT in Neonates" table); usual dosage range: 1 to 5 mcg/kg/minute; doses up to 8 mcg/kg/minute have been used; maximum adult dose: 10 mcg/kg/minute.

Argatroban Dose Adjustments to Achieve Target aPTT in Neonates
aPTT	Argatroban titration	Time to repeat aPTT^a
^aConsider more frequent aPTT monitoring based on clinical scenario. ^bRound dose up to closest second decimal (hundredth place). ^c Recommendation in patient with normal liver function; in patients with significant liver impairment, hold infusion for 2 hours then recheck aPTT before restarting (see "Altered liver function"). Adapted from ACTION 2020.
≥15 to 30 seconds below goal range	Increase infusion by 25%^b	2 to 3 hours
5 to <15 seconds below goal range	Increase infusion by 15%^b	2 to 3 hours
Within goal range	No change	2 to 3 hours; then daily after 2 consecutive aPTTs within goal range
5 to <15 seconds above goal range	Decrease infusion by 15%^b	2 to 3 hours
≥15 to 30 seconds above goal range	Decrease infusion by 25%^b	2 to 3 hours
>3× baseline or > approximately 120 seconds	Hold infusion for 15 minutes and decrease infusion by 30%^b,c	2 hours

Altered liver function:

Heparin-induced thrombocytopenia:

AST or ALT ≥3 times ULN:

Term Neonates:

Initial dose: Continuous IV Infusion: Consider a lower initial dose in the setting of liver dysfunction (eg. 0.2 mcg/kg/minute) (Ref).

Maintenance dose: Measure aPTT 2 hours after any dose change and at least once daily; more frequent monitoring may be required based on clinical status; adjust dose until the steady-state aPTT is 1.5 to 3 times the initial baseline value (depends on bleeding risk), not exceeding 100 seconds; adjust in increments of ≤0.05 mcg/kg/minute (Ref).

Ventricular assist device (VAD):

Neonates: Continuous IV infusion (Ref):

Baseline liver impairment:

Initial dose: Consider lower initial dose with known liver impairment and baseline elevated INR.

Liver impairment during treatment:

Maintenance dose: Check aPTT and monitor closely.

Significant liver impairment during treatment:

aPTT >3 times baseline or > approximately 120 seconds: Hold infusion for 2 hours then recheck aPTT before restarting.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Pediatric

Heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia (HIT): Limited data available: Note: Required maintenance dose is highly variable between patients; frequent dosage adjustments required in critically ill patients and/or patients with liver impairment to maintain desired anticoagulant activity.

Infants, Children, and Adolescents ≤16 years: Continuous IV infusion:

Initial dose: 0.75 mcg/kg/minute; measure aPTT after 2 hours; titrate to maintain aPTT in desired range; adjust in increments of 0.1 to 0.25 mcg/kg/minute for normal liver function; dosing based on population modeling and simulations (Ref). Note: A lower initial infusion rate may be needed for critically ill patients and/or patients with liver impairment.

Conversion to oral anticoagulant: Because there may be a combined effect on the INR when argatroban is combined with warfarin, loading doses of warfarin should not be used. Warfarin therapy should be started at the expected daily dose. Once combined INR on warfarin and argatroban is >4, stop argatroban. Repeat INR measurement in 4 to 6 hours; if INR is below therapeutic level, argatroban therapy may be restarted. Repeat procedure daily until desired INR on warfarin alone is obtained. Another option is to use factor X levels to monitor the effect of warfarin anticoagulation. When factor X level is <0.3, warfarin is considered therapeutic and at which time argatroban can be discontinued (Ref).

Anticoagulation, mechanical circulatory support

Anticoagulation, mechanical circulatory support:

Ventricular assist device (VAD) (Ref): Very limited data available:

Note: Dosing based on a consensus protocol; goal aPTT range determined by risk of bleeding and thrombosis and postoperative phase of care.

Infants, Children, and Adolescents: Initial dose: Continuous IV infusion: 0.5 mcg/kg/minute; consider a lower initial dose in the setting of liver dysfunction with baseline elevated INR; titrate to achieve target aPTT (See "Argatroban Dose Adjustments to Achieve Target aPTT in Infants, Children, and Adolescents" table); usual dosage range: 1 to 5 mcg/kg/minute; doses up to 8 mcg/kg/minute have been used; maximum adult dose: 10 mcg/kg/minute.

Argatroban Dose Adjustments to Achieve Target aPTT in Infants, Children, and Adolescents
aPTT	Argatroban titration	Time to repeat aPTT^a
^aConsider more frequent aPTT monitoring based on clinical scenario. ^bRound dose up to closest second decimal (hundredth place). ^c Recommendation in patient with normal liver function; in patients with significant liver impairment, hold infusion for 2 hours then recheck aPTT before restarting (see "Dosing: Altered Liver Function: Pediatric"). Adapted from ACTION 2020.
≥15 to 30 seconds below goal range	Increase infusion by 25%^b	2 to 3 hours
5 to <15 seconds below goal range	Increase infusion by 15%^b	2 to 3 hours
Within goal range	No change	2 to 3 hours; then daily after 2 consecutive aPTTs within goal range
5 to <15 seconds above goal range	Decrease infusion by 15%^b	2 to 3 hours
≥15 to 30 seconds above goal range	Decrease infusion by 25%^b	2 to 3 hours
>3× baseline or > approximately 120 seconds	Hold infusion for 15 minutes and decrease infusion by 30%^b,c	2 hours

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

Mild to severe impairment: There are no pediatric-specific dosage adjustments provided in the manufacturer's labeling; however, based on consensus protocol and adult information, no dosage adjustment necessary (Ref).

Dialysis: Based on adult information, ~20% argatroban removed over 4 hours during hemodialysis (Ref); removal during hemodialysis and continuous venovenous hemofiltration did not alter clinical efficacy when used for anticoagulation in renal replacement therapy (Ref).

Dosing: Liver Impairment: Pediatric

There are no pediatric-specific dosage adjustments provided in the manufacturer's labeling; decreased clearance has been reported in pediatric patients with liver impairment; the dose should be reduced:

Heparin-induced thrombocytopenia (HIT):

Infants, Children, and Adolescents ≤16 years:

AST or ALT ≥3 times ULN:

Initial dose: Continuous IV Infusion: Reduce initial dose to 0.2 mcg/kg/minute; measure aPTT after 2 hours and adjust dose to maintain aPTT in the desired range; adjust in increments of ≤0.05 mcg/kg/minute (Ref).

Ventricular assist device (VAD):

Infants, Children, and Adolescents: Continuous IV Infusion (Ref):

Baseline liver impairment:

Initial dose: Consider dosage reduction if known impairment and baseline elevated INR.

Liver impairment during treatment:

Maintenance dose: Check aPTT and monitor closely.

Significant liver impairment during treatment:

aPTT >3 times baseline or > approximately 120 seconds: Hold infusion for 2 hours then recheck aPTT before restarting.

Dosing: Adult

(For additional information see "Argatroban: Drug information")

Heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia:

Note: After adjustment of the initial dosing as recommended below, doses in the lower end of the range are usually necessary for patients with hepatic impairment and/or heart failure.

Critically ill:

Continuous IV infusion: Initial: 0.5 mcg/kg/minute; adjust dose based on aPTT results (measured 2 hours after initiation then every 4 hours) until steady state aPTT is 1.5 to 3 times the initial baseline value, not exceeding 100 seconds. Usual dosing range: 0.1 to 1.5 mcg/kg/minute; dosage should not exceed 10 mcg/kg/minute (Ref).

Noncritically ill:

Continuous IV infusion: Initial: 2 mcg/kg/minute; adjust dose based on aPTT results (measured 2 hours after initiation then every 4 hours) until steady state aPTT is 1.5 to 3 times the initial baseline value, not exceeding 100 seconds; dosage should not exceed 10 mcg/kg/minute (Ref).

Conversion to oral anticoagulant:

Note: Also consider referring to institutional protocols; optimal approach for conversion to oral therapy has not been established.

Conversion to warfarin: Because there may be a combined effect on the INR when argatroban is used concomitantly with warfarin, loading doses of warfarin should not be used. Initiate warfarin therapy at the expected daily dose. Optimal conversion strategy has not been identified if INR is already >4 on argatroban alone (eg, before starting warfarin); refer to institutional protocols.

Patients receiving ≤2 mcg/kg/minute of argatroban: Argatroban therapy can be stopped when the INR is >4 on combined warfarin and argatroban therapy; repeat INR measurement in 4 to 6 hours; if INR is below therapeutic level, argatroban therapy may be restarted. Repeat procedure daily until desired INR on warfarin alone is obtained.

Patients receiving >2 mcg/kg/minute of argatroban: Reduce dose of argatroban to 2 mcg/kg/minute; measure INR for argatroban and warfarin 4 to 6 hours after dose reduction; argatroban therapy can be stopped when the INR on warfarin and argatroban combined therapy is >4. Repeat INR measurement in 4 to 6 hours; if INR is below therapeutic level, argatroban therapy may be restarted. Repeat procedure daily until desired INR on warfarin alone is obtained.

Note: The American College of Chest Physicians suggests monitoring chromogenic factor X assay when transitioning from argatroban to warfarin (Ref) or overlapping administration of warfarin for a minimum of 5 days until INR is within target range; recheck INR after anticoagulant effect of argatroban has dissipated (Ref). Factor X levels <45% have been associated with INR values >2 after the effects of argatroban have been eliminated (Ref).

Conversion to a direct-acting oral anticoagulant: Start direct-acting oral anticoagulant when argatroban infusion is stopped (consult institutional protocol if the aPTT is above the target range) (Ref).

Percutaneous coronary intervention

Percutaneous coronary intervention: IV:

Initial: Begin infusion of 25 mcg/kg/minute and administer bolus dose of 350 mcg/kg (over 3 to 5 minutes). ACT should be checked 5 to 10 minutes after bolus infusion; proceed with procedure if ACT >300 seconds.

Following initial bolus:

ACT <300 seconds: Give an additional 150 mcg/kg bolus, and increase infusion rate to 30 mcg/kg/minute (recheck ACT in 5 to 10 minutes).

ACT >450 seconds: Decrease infusion rate to 15 mcg/kg/minute (recheck ACT in 5 to 10 minutes).

Once a therapeutic ACT (300 to 450 seconds) is achieved, infusion should be continued for the duration of the procedure.

If dissection, impending abrupt closure, thrombus formation during PCI, or inability to achieve ACT >300 seconds: An additional bolus of 150 mcg/kg, followed by an increase in infusion rate to 40 mcg/kg/minute may be administered (recheck ACT after each additional bolus or change in infusion rate).

Note: Post-PCI anticoagulation, if required, may be achieved by continuing infusion at a reduced dose of 2 mcg/kg/minute, with close monitoring of aPTT; adjust infusion rate as needed. Recheck ACT after each additional bolus or change in infusion rate.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Altered kidney function: IV: No dosage adjustment necessary for any degree of kidney dysfunction (Ref).

Augmented renal clearance (measured urinary CrCl ≥130 mL/minute/1.73 m²):

Note: Augmented renal clearance (ARC) is a condition that occurs in certain critically ill patients without organ dysfunction and with normal serum creatinine concentrations. Younger patients (<55 years of age) admitted post trauma or major surgery are at highest risk for ARC, as well as those with sepsis, burns, or hematologic malignancies. An 8- to 24-hour measured urinary CrCl is necessary to identify these patients (Ref).

IV: No data; no dosage adjustment necessary (Ref).

Hemodialysis, intermittent (thrice weekly): Not significantly dialyzable: Dialytic clearance increases systemic clearance 20% during the procedure without any significant impact on clotting measures (activated clotting time [ACT]) (Ref).

IV: No dosage adjustment or supplemental dose necessary (Ref).

Peritoneal dialysis: Unlikely to be significantly dialyzable (Ref):

IV: No dosage adjustment necessary (Ref).

CRRT: IV: No dosage adjustment necessary (Ref).

PIRRT (eg, sustained, low-efficiency diafiltration): IV: No dosage adjustment necessary (Ref).

Dosing: Liver Impairment: Adult

The liver dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Matt Harris, PharmD, MHS, BCPS, FAST, FCCP; Jeong Park, PharmD, MS, BCTXP, FCCP, FAST; Arun Jesudian, MD; Sasan Sakiani, MD.

Note: Argatroban is primarily eliminated by the hepatobiliary system. In patients with Child-Turcotte-Pugh class B or C, clearance is reduced, and elimination half-life is prolonged; further accumulation may occur in critically ill patients or patients with altered kidney function or occult liver dysfunction (Ref). Consider use of alternative agents (eg, bivalirudin) in the setting of liver insufficiency (Ref).

Liver impairment prior to treatment initiation:

Initial or dose titration in patients with preexisting liver cirrhosis :

Heparin-induced thrombocytopenia:

Child-Turcotte-Pugh class A: IV: No dosage adjustment necessary (Ref).

Child-Turcotte-Pugh class B: IV: Initial: 0.5 mcg/kg/minute; consider measuring aPTT 2 hours after start of therapy and then every 4 to 6 hours to allow for steady-state to be achieved; further adjust dose per goal aPTT or institutional protocol (Ref).

Child-Turcotte-Pugh class C: IV: Initial: 0.25 mcg/kg/minute; consider measuring aPTT 2 hours after start of therapy and then every 4 to 6 hours to allow for steady-state to be achieved; further adjust dose per goal aPTT or institutional protocol (Ref).

Percutaneous coronary intervention :Use not recommended, consider alternative agents (Ref).

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Adverse reactions are reported for adults treated for heparin-induced thrombocytopenia (HIT) and percutaneous coronary intervention with or without heparin-induced thrombocytopenia (PCI), unless otherwise specified.

>10%:

Cardiovascular: Chest pain (PCI: 15%), hypotension (7% to 11%)

Gastrointestinal: Gastrointestinal hemorrhage (major: ≤2%; minor: Including hematemesis: HIT: 14%, PCI: ≤3%)

Genitourinary: Genitourinary tract hemorrhage (including hematuria; major: HIT: <1%; minor: HIT: 12%, PCI: 2%)

1% to 10%:

Cardiovascular: Acute myocardial infarction (PCI: 4%), angina pectoris (PCI: 2%), brachial artery hemorrhage (minor: HIT: 2%), bradycardia (PCI: 5%), coronary occlusion (PCI: 2%), coronary thrombosis (PCI: 2%), ischemic heart disease (PCI: 2%), ventricular tachycardia (HIT: 5%)

Gastrointestinal: Abdominal pain (3% to 4%), diarrhea (HIT: 6%), nausea (5% to 7%), vomiting (4% to 6%)

Hematologic & oncologic: Decreased hematocrit (major: HIT: <1%; minor: HIT: ≤10%, PCI: ≤2%), decreased hemoglobin (major: HIT: <1%; minor: HIT: ≤10%, PCI: ≤2%), groin bleeding (including hematoma; minor: 4% to 5%), hemorrhage (major hemorrhage: HIT: 5%; minor: PCI [CABG related]: 2%)

Nervous system: Headache (PCI: 5%), pain (HIT: 5%)

Neuromuscular & skeletal: Back pain (PCI: 8%)

Respiratory: Cough (HIT: 3%), hemoptysis (minor: ≤3%)

Miscellaneous: Fever (≤7%)

<1%:

Cardiovascular: Aortic valve stenosis (PCI), atrial thrombosis (PCI), vascular disease (PCI)

Gastrointestinal: Gastroesophageal reflux disease (PCI)

Hematologic & oncologic: Disseminated intravascular coagulation (HIT), retroperitoneal bleeding (PCI)

Local: Bleeding at injection site (access site: PCI), local hemorrhage (limb and below-the-knee stump: HIT)

Nervous system: Cerebrovascular disease (PCI)

Respiratory: Pulmonary edema (PCI)

Frequency not defined: Hypersensitivity: Hypersensitivity reaction

Contraindications

Hypersensitivity to argatroban or any component of the formulation; major bleeding.

Canadian labeling: Additional contraindications (not in US labeling): Hereditary fructose intolerance.

Warnings/Precautions

Concerns related to adverse effects:

• Bleeding: The most common complication is bleeding and can occur at any site in the body. Use extreme caution in patients with hematologic conditions associated with increased bleeding (eg, congenital or acquired bleeding disorders, GI lesions); recent puncture of large vessels or organ biopsy; spinal anesthesia; immediately following lumbar puncture; recent cerebrovascular accident (CVA), stroke, intracerebral surgery, or other neuraxial procedure; severe hypertension; renal impairment; recent major surgery; recent major bleeding (intracranial, GI, intraocular, or pulmonary). Monitor for signs and symptoms of bleeding.

• Hypersensitivity: Airway, skin, and generalized hypersensitivity reactions have been reported.

Special populations:

• Critically ill patients: Use with caution in critically-ill patients; reduced clearance may require dosage reduction.

Dosage Forms: US

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

Solution, Intravenous:

Generic: 50 mg/50 mL (50 mL); 250 mg/2.5 mL (2.5 mL); 50 mg/50 mL in NaCl 0.9% (50 mL)

Solution, Intravenous [preservative free]:

Generic: 50 mg/50 mL (50 mL); 50 mg/50 mL in NaCl 0.9% (50 mL)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Argatroban in Sodium Chloride Intravenous)

50 mg/50 mL 0.9% (per mL): $4.68 - $5.85

Solution (Argatroban Intravenous)

50 mg/50 mL (per mL): $2.40 - $4.75

250 mg/2.5 mL (per mL): $91.20 - $244.80

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, Intravenous:

Generic: 50 mg/50 mL (50 mL); 250 mg/2.5 mL (2.5 mL)

Additional Information

Molecular weight: 526.66; argatroban is a synthetic anticoagulant (direct thrombin inhibitor) derived from L-arginine. Increases in aPTT, activated clotting time (ACT), PT, INR, and thrombin time (TT) occur in a dose-dependent fashion with increasing doses of argatroban. Adult studies have established the use of aPTT for patients with heparin-induced thrombocytopenia and ACT for patients with percutaneous coronary intervention procedures. Therapeutic ranges for PT, INR, and TT have not been identified.

A reversal agent to argatroban is not available. Should life-threatening bleeding occur, discontinue argatroban immediately, obtain an aPTT and other coagulation tests, and provide symptomatic and supportive care.

Administration: Pediatric

Parenteral: Continuous IV infusion: Vials (concentrated solution) must be diluted prior to administration; premixed IV solution (1 mg/mL) is available. Administer as a continuous IV infusion with the use of an infusion pump.

Administration: Adult

IV: The 2.5 mL (100 mg/mL) concentrated vial must be diluted to 1 mg/mL prior to administration. The premixed vial requires no further dilution. The premixed 1 mg/mL vial may be inverted for use with an infusion set. For HIT, administer by continuous IV infusion. For PCI, administer by IV infusion and bolus (over 3 to 5 minutes through a large bore IV line).

Usual Infusion Concentrations: Pediatric

Note: Premixed solutions available.

IV infusion: 1 mg/mL.

Storage/Stability

Vials, 2.5 mL (100 mg/mL) concentrate: Prior to use, store vial in original carton at 20°C to 25°C (68°F to 77°F). Do not freeze. Protect from light. The prepared solution, diluted in D5W, LR, or NS, is stable for 24 hours at 20°C to 25°C (68°F to 77°F) in ambient indoor light. Do not expose prepared solutions to direct sunlight. Prepared solutions that are protected from light and kept at 20°C to 25°C (68°F to 77°F) or under refrigeration at 2°C to 8°C (36°F to 46°F) are stable for up to 96 hours.

Premixed vials: Store in original carton at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Do not refrigerate or freeze. Protect from light.

Use

Prophylaxis or treatment of thrombosis in patients with heparin-induced thrombocytopenia (HIT) (FDA approved in adults); anticoagulant for percutaneous coronary intervention (PCI) in patients who have or are at risk for HIT (FDA approved in adults); has also been used for anticoagulation in patients with ventricular assist device.

Medication Safety Issues

Sound-alike/look-alike issues:

Argatroban may be confused with Aggrastat, Orgaran

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (direct thrombin inhibitor) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care, Community/Ambulatory Care, and Long-Term Care Settings).

National Patient Safety Goals:

The Joint Commission (TJC) requires healthcare organizations that provide anticoagulant therapy to have approved protocols and evidence-based practice guidelines in place to reduce the risk of anticoagulant-associated patient harm. Patients receiving anticoagulants should receive individualized care through a defined process that includes medication selection, dosing (including adjustments for age, renal function, or liver function), drug-drug interactions, drug-food interactions, other applicable risk factors, monitoring, patient and family education, proper administration, reversal of anticoagulation, management of bleeding events, and perioperative management. This does not apply to routine short-term use of anticoagulants for prevention of venous thromboembolism during procedures or hospitalizations (NPSG.03.05.01).

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.

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

Acalabrutinib: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Aducanumab: May increase anticoagulant effects of Anticoagulants. Management: Avoid use of anticoagulants in patients being treated with aducanumab when possible. If concurrent use is necessary, monitor closely for evidence of intracerebral hemorrhage or other bleeding. Risk D: Consider Therapy Modification

Alemtuzumab: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Alteplase: May increase anticoagulant effects of Anticoagulants. Risk X: Avoid

Anacaulase: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Anagrelide: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Antidepressants with Antiplatelet Effects: May increase anticoagulant effects of Anticoagulants (Miscellaneous Agents). Risk C: Monitor

Apixaban: May increase anticoagulant effects of Anticoagulants. Refer to separate drug interaction content and to full drug monograph content regarding use of apixaban with vitamin K antagonists (eg, warfarin, acenocoumarol) during anticoagulant transition and bridging periods. Risk X: Avoid

Aspirin: May increase anticoagulant effects of Anticoagulants (Miscellaneous Agents). Risk C: Monitor

Bromperidol: May increase adverse/toxic effects of Anticoagulants. Risk C: Monitor

Caplacizumab: May increase anticoagulant effects of Anticoagulants. Management: Avoid coadministration of caplacizumab with antiplatelets if possible. If coadministration is required, monitor closely for signs and symptoms of bleeding. Interrupt use of caplacizumab if clinically significant bleeding occurs. Risk D: Consider Therapy Modification

Chloroprocaine (Systemic): Anticoagulants may increase adverse/toxic effects of Chloroprocaine (Systemic). Risk C: Monitor

Cilostazol: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Collagenase (Systemic): Anticoagulants 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: May increase anticoagulant effects of Anticoagulants. Refer to separate drug interaction content and to full drug monograph content regarding use of dabigatran etexilate with vitamin K antagonists (eg, warfarin, acenocoumarol) during anticoagulant transition and bridging periods. Risk X: Avoid

Dasatinib: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Deferasirox: Anticoagulants may increase adverse/toxic effects of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Risk C: Monitor

Defibrotide: May increase anticoagulant effects of Anticoagulants. Risk X: Avoid

Deoxycholic Acid: Anticoagulants may increase adverse/toxic effects of Deoxycholic Acid. Specifically, the risk for bleeding or bruising in the treatment area may be increased. Risk C: Monitor

Desirudin: Anticoagulants may increase anticoagulant effects of Desirudin. Management: Discontinue treatment with other anticoagulants prior to desirudin initiation. If concomitant use cannot be avoided, monitor patients receiving these combinations closely for clinical and laboratory evidence of excessive anticoagulation. Risk D: Consider Therapy Modification

Donanemab: May increase anticoagulant effects of Anticoagulants. Management: Avoid use of anticoagulants in patients being treated with donanemab when possible. If concurrent use is necessary, monitor closely for evidence of intracerebral hemorrhage or other bleeding. Risk D: Consider Therapy Modification

Edoxaban: May increase anticoagulant effects of Anticoagulants. Refer to separate drug interaction content and to full drug monograph content regarding use of edoxaban with vitamin K antagonists (eg, warfarin, acenocoumarol) during anticoagulant transition and bridging periods. Management: Some limited combined use may be indicated during periods of transition from one anticoagulant to another. See the full edoxaban drug monograph for specific recommendations on switching anticoagulant treatment. Risk X: Avoid

Hemin: May increase anticoagulant effects of Anticoagulants. Risk X: Avoid

Herbal Products with Anticoagulant/Antiplatelet Effects: May increase adverse/toxic effects of Anticoagulants. Bleeding may occur. Risk C: Monitor

Ibritumomab Tiuxetan: Anticoagulants may increase adverse/toxic effects of Ibritumomab Tiuxetan. Both agents may contribute to an increased risk of bleeding. Risk C: Monitor

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

Icosapent Ethyl: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Inotersen: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Kanamycin: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Lecanemab: May increase adverse/toxic effects of Anticoagulants. Specifically, the risk of hemorrhage may be increased. Management: Avoid use of lecanemab in patients who are being treated with an anticoagulant when possible. If concurrent use is necessary, monitor closely for evidence of intracerebral hemorrhage or other bleeding. Risk D: Consider Therapy Modification

Limaprost: May increase adverse/toxic effects of Anticoagulants. The risk for bleeding may be increased. Risk C: Monitor

Lipid Emulsion (Fish Oil Based): May increase anticoagulant effects of Anticoagulants. Lipid Emulsion (Fish Oil Based) may decrease anticoagulant effects of Anticoagulants. Risk C: Monitor

Mesoglycan: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

MiFEPRIStone: May increase adverse/toxic effects of Anticoagulants. Specifically, the risk of bleeding may be increased. Risk X: Avoid

Nintedanib: Anticoagulants may increase adverse/toxic effects of Nintedanib. Specifically, the risk for bleeding may be increased. Risk C: Monitor

Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective): May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Nonsteroidal Anti-Inflammatory Agents (Nonselective): May increase anticoagulant effects of Anticoagulants (Miscellaneous Agents). Risk C: Monitor

Nonsteroidal Anti-Inflammatory Agents (Ophthalmic): May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Nonsteroidal Anti-Inflammatory Agents (Topical): May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Obinutuzumab: Anticoagulants may increase adverse/toxic effects of Obinutuzumab. Specifically, the risk of serious bleeding-related events may be increased. Management: Consider avoiding coadministration of obinutuzumab and anticoagulants, especially during the first cycle of obinutuzumab therapy. Risk D: Consider Therapy Modification

Omacetaxine: Anticoagulants may increase adverse/toxic effects of Omacetaxine. Specifically, the risk for bleeding-related events may be increased. Management: Avoid concurrent use of anticoagulants with omacetaxine in patients with a platelet count of less than 50,000/uL. Risk X: Avoid

Omega-3 Fatty Acids: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Oritavancin: May decrease therapeutic effects of Anticoagulants. Specifically, oritavancin may artificially increase the results of laboratory tests commonly used to monitor anticoagulant effectiveness, which could lead to incorrect decisions to decrease anticoagulant doses. Risk C: Monitor

Ozagrel: May increase anticoagulant effects of Anticoagulants. Management: Avoid coadministration of ozagrel and anticoagulants if possible. If coadministration is required, use caution, monitor patients closely for signs and symptoms of bleeding, and consider ozagrel or anticoagulant dose reductions. Risk D: Consider Therapy Modification

Pentosan Polysulfate Sodium: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Pirtobrutinib: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Protein C Concentrate (Human): May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Reteplase: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Rivaroxaban: Anticoagulants may increase anticoagulant effects of Rivaroxaban. Refer to separate drug interaction content and to full drug monograph content regarding use of rivaroxaban with vitamin K antagonists (eg, warfarin, acenocoumarol) during anticoagulant transition and bridging periods. Risk X: Avoid

Salicylates: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Streptokinase: May increase anticoagulant effects of Anticoagulants. Risk X: Avoid

Sugammadex: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Sulodexide: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Telavancin: May decrease therapeutic effects of Anticoagulants. Specifically, telavancin may artificially increase the results of laboratory tests commonly used to monitor anticoagulant effectiveness, which could lead to incorrect decisions to decrease anticoagulant doses. Risk C: Monitor

Tenecteplase: May increase anticoagulant effects of Anticoagulants. Risk X: Avoid

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

Tibolone: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Tipranavir: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Urokinase: May increase anticoagulant effects of Anticoagulants. Management: Consider avoiding this combination due to an increased risk of hemorrhage. If anticoagulants are coadministered with urokinase, monitor patients closely for signs and symptoms of bleeding. Risk D: Consider Therapy Modification

Vitamin E (Systemic): May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Vitamin K Antagonists: Anticoagulants may increase anticoagulant effects of Vitamin K Antagonists. Risk C: Monitor

Volanesorsen: May increase anticoagulant effects of Anticoagulants. Risk C: Monitor

Vorapaxar: May increase adverse/toxic effects of Anticoagulants. More specifically, this combination is expected to increase the risk of bleeding. Risk X: Avoid

Zanubrutinib: May increase adverse/toxic effects of Anticoagulants. Risk C: Monitor

Pregnancy Considerations

Information related to argatroban in pregnancy is limited. Use of parenteral direct thrombin inhibitors in pregnancy should be limited to those women who have severe allergic reactions to heparin, including heparin-induced thrombocytopenia, and who cannot receive danaparoid (Guyatt 2012).

Monitoring Parameters

Heparin-induced thrombocytopenia: Obtain baseline aPTT prior to start of therapy. Check aPTT 2 hours after start of therapy and after any dosage adjustment. Monitor hemoglobin, hematocrit, platelets, and signs and symptoms of bleeding. Monitor hepatic function tests at baseline and as clinically indicated.

Ventricular assist device (VAD): Monitor aPTTs per dosing recommendations. Monitor hemoglobin, hematocrit, platelets, and signs and symptoms of bleeding. Monitor hepatic function tests at baseline and as clinically indicated.

Reference Range

Heparin-induced thrombocytopenia (HIT):

Neonates, Infants, Children, and Adolescents ≤16 years: Standard aPTT goal: 1.5 to 3 times the baseline aPTT (Young 2011).

Ventricular assist device (VAD):

Neonates, Infants, Children, and Adolescents:

Standard aPTT goal: 1.5 to 3 times the baseline aPTT (ACTION 2020).

Consensus protocol has suggested the following aPTT goals based on bleeding risk (ACTION 2020):

Initial dose:

High risk of bleeding: aPTT: 50 to 60 seconds.

Maintenance doses:

Standard risk: aPTT: 60 to 80 seconds.

High risk of thrombosis: aPTT: 70 to 90 seconds.

Mechanism of Action

A direct, highly-selective thrombin inhibitor. Reversibly binds to the active thrombin site of free and clot-associated thrombin. Inhibits fibrin formation; activation of coagulation factors V, VIII, and XIII; activation of protein C; and platelet aggregation.

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: Immediate

Distribution: 174 mL/kg

Protein binding: Albumin: 20%; alpha₁-acid glycoprotein: 34%

Metabolism: Hepatic via hydroxylation and aromatization (major route). Metabolism via CYP3A4/5 (minor route) to four metabolites. Unchanged argatroban is the major plasma component. Plasma concentration of metabolite M1 is 0% to 20% of the parent drug and is three- to five-fold weaker.

Half-life elimination: 39 to 51 minutes; Hepatic impairment: 181 minutes

Time to peak: Steady-state: 1 to 3 hours

Excretion: Feces (~65%; 14% unchanged); urine (~22%; 16% unchanged); low quantities of metabolites M2-4 in urine

Clearance:

Pediatric patients (seriously ill): 0.16 L/kg/hour; 50% lower than healthy adults

Pediatric patients (seriously ill with elevated bilirubin due to hepatic impairment or cardiac complications; n=4): 0.03 L/kg/hour; 80% lower than pediatric patients with normal bilirubin

Adult: 0.31 L/kg/hour (5.1 mL/kg/minute); hepatic impairment: 1.9 mL/kg/minute

Brand Names: International

International Brand Names by Country

For country code abbreviations (show table)

(AE) United Arab Emirates: Exembol;
(AT) Austria: Argatra | Argatroban accord;
(CH) Switzerland: Argatra;
(DE) Germany: Argatra | Argatroban accord;
(EE) Estonia: Exembol multidose;
(ES) Spain: Arganova;
(FI) Finland: Novastan;
(FR) France: Arganova | Argatroban accord;
(GB) United Kingdom: Exembol;
(HU) Hungary: Argatra;
(IT) Italy: Novastan;
(JP) Japan: Argatroban hi fuso | Argatroban sn | Slonnon Hi;
(LT) Lithuania: Argatra;
(NL) Netherlands: Arganova | Arganova multidose;
(NO) Norway: Argatra;
(PL) Poland: Argatra;
(SE) Sweden: Novastan

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Argatroban injection 50 mg per 50 mL (1 mg per mL) [prescribing information]. Schaumburg, IL: Sagent Pharmaceuticals; March 2021.
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Topic 13081 Version 332.0

خرید پکیج

Argatroban: Pediatric drug information