eptifibatide

General

High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error.

Pronunciation
ep-ti-FIB-a-tide [Pronunciation]

Trade Name(s)

• Integrilin

Pregnancy Category
Category B

Ther. class.
antiplatelet agents

Pharm. class.
glycoprotein iib iiia inhibitors

Indications

• Acute coronary syndrome (unstable angina/non–Q-wave MI), including patients who will be managed medically and those who will undergo percutaneous coronary intervention (PCI) that may consist of percutaneous transluminal angioplasty (PCTA) or atherectomy.

• Treatment of patients undergoing PCI.

• Usually used concurrently with aspirin and heparin.

Action

Decreases platelet aggregation by reversibly antagonizing the binding of fibrinogen to the glycoprotein IIb/IIIa binding site on platelet surfaces.

Therapeutic Effect(s):
Inhibition of platelet aggregation resulting in decreased incidence of new MI, death, or refractory ischemia, reducing the need for repeat urgent cardiac intervention.

Pharmacokinetics

Absorption: IV administration results in complete bioavailability.

Distribution: Unknown.

Metabolism and Excretion: 50% excreted by the kidneys.

Half-life: 2.5 hr.

TIME/ACTION PROFILE (effects on platelet function)

ROUTE	ONSET	PEAK	DURATION
IV	immediate	following bolus	brief†

†Inhibition is reversible following cessation of infusion

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity;

• Active internal bleeding or history of bleeding within previous 30 days;

• Severe uncontrolled hypertension (systolic BP >200 mm Hg and/or diastolic BP >110 mm Hg);

• Major surgical procedure within 6 wk;

• History of hemorrhagic stroke or other stroke within 30 days;

• Concurrent use of other glycoprotein IIb/IIIa receptor antagonists;

• Platelet count <100,000/mm³;

• Severe renal insufficiency (serum creatinine ≥4 mg/dL) or dependency on renal dialysis.

Use Cautiously in:

• Geri: ↑ risk of bleeding ;

• Renal insufficiency (↓ infusion rate if CCr < 50 mL/min);

• OB: Pregnancy, lactation, or children (safety not established; use in pregnancy only if clearly needed).

Adverse Reactions/Side Effects

Noted for patients receiving heparin and aspirin in addition to eptifibatide

CV: hypotension.

Hemat: BLEEDING (INCLUDING GI AND INTRACRANIAL BLEEDING, HEMATURIA, AND HEMATOMAS) , thrombocytopenia.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Interactions

Drug-Drug
↑ risk of bleeding with other drugs that affect hemostasis ( heparins , warfarin , NSAIDs , thrombolytic agents , abciximab , dipyridamole , ticlopidine , clopidogrel , some cephalosporins , valproates ).

Drug-Natural Products
↑ bleeding risk with arnica , chamomile , clove , dong quai , feverfew , garlic , ginger , ginkgo , and Panax ginseng .

Route/Dosage

Acute Coronary Syndrome

• IV (Adults ≤121 kg): 180 mcg/kg as a bolus dose, followed by 2 mcg/kg/min until hospital discharge or surgical intervention (up to 72 hr)..

Percutaneous Coronary Intervention

• IV (Adults): 180 mcg/kg as a bolus dose, immediately before PCI, followed by 2 mcg/kg/min infusion; a second bolus of 180 mcg/kg is given 10 min after first bolus; infusion should continue for 18–24 or hospital discharge (minimum of 12 hr)..

Renal Impairment

• (Adults CCr <50 mL/min): 180 mcg/kg bolus followed by 1 mcg/kg/min infusion; second bolus of 180 mcg/kg is given 10 min after first bolus for patients undergoing PCI..

Availability

• Solution for injection: 20 mg/10 mL, 75 mg/100 mL, 200 mg/100 mL

Assessment

• Assess for bleeding. Most common sites are arterial access site for cardiac catheterization or GI or GU tract. Arterial and venous punctures, IM injections, and use of urinary catheters, nasotracheal intubation, and NG tubes should be minimized. Noncompressible sites for IV access should be avoided. If bleeding cannot be controlled with pressure, discontinue eptifibatide and heparin immediately.

Lab Test Considerations

• Prior to eptifibatide therapy, assess hemoglobin or hematocrit, platelet count, serum creatinine, and PT/aPTT. Activated clotting time (ACT) should also be measured in patients undergoing PCI.

» Maintain the aPTT between 50 and 70 sec unless PCI is to be performed. Maintain ACT between 300 and 350 sec during PCI.

» Arterial sheath should not be removed unless aPTT <45 sec.

» If platelet count decreases to <100,000 and is confirmed, eptifibatide and heparin should be discontinued and condition monitored and treated.

Potential Nursing Diagnoses

• Ineffective tissue perfusion (Indications)

Implementation

• High Alert: Accidental overdose of antiplatelet medications has resulted in patient harm or death from internal hemorrhage or intracranial bleeding. Have second practitioner independently check original order, dose calculations, and infusion pump settings.

• Most patients receive heparin and aspirin concurrently with eptifibatide.

» After PCI, femoral artery sheath may be removed during eptifibatide treatment only after heparin has been discontinued and its effects mostly reversed.

» Do not administer solutions that are discolored or contain particulate matter. Discard unused portion.

IV Adminstration:

• pH:
5.0.

• Direct IV:
High Alert: Diluent: Withdraw appropriate loading dose from bolus vial (20 mg/10-mL vial) into a syringe. Administer undiluted

Concentration: 2 mg/mL.

• Rate:
Administer over 1–2 min.

• Continuous Infusion:

Diluent: Administer undiluted directly from the 100-mL vial via an infusion pump.
Concentration: 0.75 mg/mL or 2 mg/mL (depends on vial used).

• Rate:
Based on patient's weight (see Route/Dosage section).

• Y-Site Compatibility:

» alemtuzumab

» alfentanil

» alteplase

» amikacin

» amiodarone

» amphotericin B lipid complex

» amphotericin B liposome

» ampicillin

» ampicillin/sulbactam

» anidulafungin

» argatroban

» atracurium

» atropine

» azithromycin

» aztreonam

» bivalirudin

» bumetanide

» buprenorphione

» butorphanol

» calcium chloride

» calcium gluconate

» cefepime

» cefoperazone

» cefotaxime

» cefotetan

» ceftazidime

» ceftriaxone

» cefuroxime

» ciprofloxacin

» cisatracurium

» clindamycin

» cyclosporine

» daptomycin

» dexamethasone

» digoxin

» diltiazem

» diphenhydramine

» dobutamine

» dolasetron

» dopamine

» doxycycline

» droperidol

» enalaprilat

» ephedrine

» epinephrine

» ertapenem

» erythromycin

» esmolol

» famotidine

» fentanil

» fluconazole

» fosphenytoin

» ganciclovir

» gentamicin

» granisetron

» haloperidol

» heparin

» hydrocortisone

» hydromorphone

» imipenem/cilastatin

» isoproterenol

» ketorolac

» labetalol

» leucovorin

» levofloxacin

» lidocaine

» linezolid

» lorazepam

» magnesium sulfate

» mannitol

» meperidine

» meropenem

» methylprednisolone

» metoclopramide

» metoprolol

» micafungin

» midazolam

» milrinone

» mivacurium

» morphine

» nalbuphine

» naloxone

» nicardipine

» nitroglycerin

» nitroprusside

» octreotide

» ondansetron

» oxytocin

» palonosetron

» pancuronium

» pemetrexed

» pentobarbital

» phenobarbital

» phenylephrine

» piperacillin/tazobactam

» potassium acetate

» potassium chloride

» potassium phosphates

» procainamide

» prochlorperazine

» promethazine

» propranolol

» ranitidine

» remifentanil

» rocuronium

» sodium bicarbonate

» sodium phosphates

» succinylcholine

» sufentanil

» teniposide

» theophylline

» ticarcillin/clavulanate

» tigecycline

» tirofiban

» tobramycin

» vancomycin

» vecuronium

» verapamil

» zidovudine

» zolendronic acid

• Y-Site Incompatibility:

» acyclovir

» amphotericin B colloid

» chlorpromazine

» diazepam

» furosemide

» methohexital

» mycophenolate

» pentamidine

» phenytoin

» thiopental

Patient/Family Teaching

• Inform patient of the purpose of eptifibatide.

• Instruct patient to notify health care professional immediately if any bleeding is noted.

Evaluation/Desired Outcomes

Inhibition of platelet aggregation, resulting in decreased incidence of new MI, death, or refractory ischemia with the need for repeat urgent cardiac intervention.