Eptifibatide (Monograph)

Brand name: Integrilin
Drug class: Platelet-aggregation Inhibitors
- Antithrombotic Agents
- Platelet-aggregation Inhibitors
- GP IIb/IIIa Receptor Inhibitors
Chemical name: Cyclic(1-6)-disulfide-N6amidino-N2-(3-mercaptopropionyl)-l-lysylglycyl-l-α-aspartyl-l-tryptophyl-l-prolyl-l-cysteinamide
Molecular formula: C₃₅H₄₉N₁₁O₉S₂
CAS number: 148031-34-9

Medically reviewed by Drugs.com on Sep 8, 2023. Written by ASHP.

Introduction

Platelet-aggregation inhibitor;¹ ² ³ ¹⁰ ¹¹ ⁷¹ a platelet glycoprotein (GP IIb/IIIa)-receptor inhibitor.² ⁶ ⁷ ¹¹ ¹⁴ ²⁶ ³⁷ ⁴⁴ ⁴⁸ ⁵⁰

Uses for Eptifibatide

Non-ST-Segment-Elevation Acute Coronary Syndromes

Adjunct to anticoagulant therapy (e.g., heparin [referring throughout this monograph to unfractionated heparin], low molecular weight heparin [LMWH]), aspirin, and a P2Y12 platelet adenosine diphosphate (ADP)-receptor antagonist (e.g., clopidogrel, prasugrel, ticagrelor) to reduce risk of acute cardiac ischemic events (death and/or MI) in patients with non-ST-segment-elevation acute coronary syndromes (NSTE ACS) (i.e., unstable angina or non-ST-segment-elevation MI [NSTEMI]) who are managed medically or with PCI.¹ ⁴ ⁸ ⁴⁰ ⁷² ¹¹³ ⁹⁹⁴ ⁹⁹⁵ ¹¹⁰⁰

Adjunctive therapy with a GP IIb/IIIa-receptor inhibitor can reduce the incidence of cardiac ischemic events, including subsequent MI and death, in patients with NSTE ACS.¹⁶ ⁴⁰ ⁴³ ⁴⁹ ⁵² ⁵⁶

The American College of Cardiology Foundation (ACCF) and AHA recommend either clopidogrel or IV administration of a GP IIb/IIIa-receptor inhibitor in addition to aspirin therapy prior to diagnostic angiography (“upstream”) in patients in whom an initial invasive management strategy is planned; eptifibatide or tirofiban is the preferred GP IIb/IIIa inhibitor for this use.⁹⁹¹ Abciximab is recommended only if there is no appreciable delay before angiography and PCI is likely to be performed.⁹⁹¹

The American College of Chest Physicians (ACCP) states that a clear risk-benefit profile has not been established for use of GP IIb/IIIa-receptor inhibitors in patients with ACS who are not routinely scheduled for early revascularization.¹⁰¹⁶

Eptifibatide and tirofiban not recommended by AHA in women with NSTE ACS who are at lower risk for adverse cardiac events and are managed with a conservative strategy, because of little demonstrated benefit and possible detrimental effects.¹²⁸

Acute Ischemic Complications of PCI

Adjunct to anticoagulant therapy (heparin, LMWH), aspirin, and a P2Y12-receptor antagonist (e.g., clopidogrel, prasugrel, ticagrelor) to reduce risk of acute ischemic complications (death, MI, and/or need for urgent revascularization procedures) in patients undergoing PCI, including coronary artery stenting.¹ ⁴ ⁸ ¹⁰ ¹¹ ¹⁶ ⁴³ ⁹⁹⁴ ⁹⁹⁵

ACCF, AHA, the Society for Cardiovascular Angiography and Interventions (SCAI), and other experts currently do not recommend routine use of GP IIb/IIIa-receptor inhibitors in patients with ST-segment-elevation MI (STEMI) undergoing PCI; however, selective use of these drugs as an adjunct to heparin may be reasonable in certain high-risk patients (e.g., those with large anterior MI and/or large thrombus).⁹⁹⁴ ¹⁰¹⁶

ACCF/AHA/SCAI state that administration of a GP IIb/IIIa-receptor inhibitor at the time of PCI as an adjunct to heparin may be particularly useful in patients with NSTE ACS who have high-risk features (e.g., elevated troponin) and are not receiving bivalirudin and are not adequately pretreated with clopidogrel.⁹⁹⁴

Regarding choice of GP IIb/IIIa-receptor inhibitor in patients undergoing PCI, IV abciximab, “double-bolus” IV eptifibatide, and high-dose tirofiban by direct IV injection all produce a high degree of platelet inhibition and reduce ischemic complications.⁹⁹⁴

Adjunctive Therapy During Thrombolysis to Prevent Reocclusion

Has been used as an adjunct to thrombolytic therapy (e.g., alteplase, tenecteplase) in a limited number of patients to prevent coronary artery reocclusion^{† [off-label]} following acute MI.⁶ ⁸ ¹³ ¹⁴ ³⁴ ⁴³

Eptifibatide Dosage and Administration

General

In patients with NSTE ACS, administer as soon as possible following diagnosis.¹ ⁸ ⁷²
Discontinue prior to CABG.¹

Adjunctive Antithrombotic Therapy: General Considerations

Used in conjunction with aspirin and heparin in clinical studies.¹ ⁴ ⁸ ¹⁰ ¹² ¹³ ¹⁴ ¹⁹ ⁴⁰
Dosage of heparin required to maintain an appropriate activated clotting time (ACT) during concomitant therapy with eptifibatide may be lower than with heparin monotherapy.¹⁹ ⁷² ¹¹³ ⁹⁹⁴ (See Specific Drugs under Interactions.)
Caution when used in patients requiring thrombolytic therapy.¹ (See Specific Drugs under Interactions.)

Adjunctive Antithrombotic Therapy When Used in Management of NSTE ACS

Aspirin: Manufacturer recommends 160–325 mg initially and daily thereafter.¹
Heparin sodium during medical management: In patients weighing ≥70 kg, 5000 units (IV loading dose) followed by continuous IV infusion of 1000 units/hour.¹ In patients weighing <70 kg, 60 units/kg followed by continuous IV infusion of 12 units/kg per hour.¹ Adjust dose to maintain a target aPTT of 50–70 seconds.¹ (See Laboratory Monitoring under Cautions.)
Heparin sodium in patients undergoing PCI: Administer multiple IV injections of heparin based on ACT determinations during PCI to achieve and maintain an ACT of ≥200 seconds.¹ ¹¹⁷ ¹¹⁸

Adjunctive Antithrombotic Therapy When Used to Reduce Risk of Acute Ischemic Complications of PCI

Aspirin: Manufacturer recommends 160–325 mg 1–24 hours prior to PCI and daily thereafter.¹ ACCF/AHA/SCAI recommends that aspirin 325 mg be given prior to PCI in patients not already receiving maintenance aspirin therapy.⁹⁹⁴ Patients already receiving maintenance aspirin therapy should receive a dose of 81–325 mg before the procedure.⁹⁹⁴
P2Y12-receptor antagonist: A loading dose of clopidogrel, prasugrel, or ticagrelor also is recommended prior to PCI in patients undergoing stent placement.⁹⁹⁴ ⁹⁹⁵
Heparin: 50–70 units/kg 6 hours prior to PCI (target ACT of ≥200 seconds).¹ Administer additional injections during PCI to maintain an ACT of 200–300 seconds.¹ (See Laboratory Monitoring under Cautions.) Consider a lower dosage of heparin in women and geriatric patients receiving a GP IIb/IIIa-receptor inhibitor to decrease the increased risk of minor bleeding.¹²⁸ Postprocedural use of heparin not recommended.¹ ¹⁰ ²⁶

Administration

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer by IV injection followed by IV infusion using a controlled-infusion device (e.g., pump).¹

For IV injection, withdraw appropriate dose from the 10-mL vial and administer undiluted.¹ ⁷¹

For continuous IV infusion, spike the 100-mL vial with a vented infusion set; center spike within the circle on stopper top.¹ Administer solution directly from vial.¹ ⁸ ⁷¹

Discard unused portion.¹

Dilution

Administer undiluted.¹

Rate of Administration

For IV injection, administer over 1–2 minutes.¹ ⁷¹

Dosage

Adults

NSTE ACS

IV

180 mcg/kg by IV injection as soon as possible following diagnosis, followed by IV infusion of 2 mcg/kg per minute until hospital discharge or initiation of CABG, or for ≤72 hours.¹ ⁸ ⁷²

If patient undergoes PCI while receiving eptifibatide, continue infusion (at 2 mcg/kg per minute) until hospital discharge or for ≤18–24 hours after procedure, whichever comes first, up to a maximum of 96 hours.¹

Acute Ischemic Complications of PCI

IV

180 mcg/kg by IV injection immediately before initiation of PCI, immediately followed by IV infusion of 2 mcg/kg per minute and a second IV injection of 180 mcg/kg 10 minutes after the first IV injection.¹ ¹¹⁷ ¹¹⁸

Continue infusion (at 2 mcg/kg per minute) until hospital discharge or for ≤18–24 hours, whichever comes first.¹ A minimum infusion period of 12 hours is recommended.¹

Prescribing Limits

Adults

NSTE ACS

IV

Maximum IV infusion of 72 hours.¹ ⁸ ⁷²

In patients undergoing PCI, maximum IV infusion of 96 hours.¹

Special Populations

Hepatic Impairment

No specific dosage recommendations at this time.⁸

Renal Impairment

NSTE ACS

No dosage adjustment required in patients with mild to moderate renal impairment (Cl_cr ≥50 mL/minute).¹

In patients with Cl_cr <50 mL/minute, 180 mcg/kg by IV injection as soon as possible following diagnosis, followed by IV infusion of 1 mcg/kg per minute.¹

Acute Ischemic Complications of PCI

In patients with Cl_cr <50 mL/minute, 180 mcg/kg by IV injection immediately before initiation of PCI, followed by IV infusion of 1 mcg/kg per minute and a second IV injection of 180 mcg/kg 10 minutes after the first IV injection.¹

Geriatric Patients

No dosage adjustment was made for geriatric patients in clinical trials.¹ (See Geriatric Use under Cautions.)

Cautions for Eptifibatide

Contraindications

History of bleeding diathesis¹ ¹⁰ ¹³ or active abnormal bleeding within previous 30 days.¹ ¹⁰ ¹² ¹³
Severe uncontrolled hypertension (SBP >200 mm Hg or DBP >110 mm Hg with antihypertensive therapy).¹ ¹⁰ ¹³
Recent (within 6 weeks) major surgery.¹ ¹⁰ ¹² ¹³
History of stroke within 30 days or any history of hemorrhagic stroke.¹ ¹⁰ ¹² ¹³
Current or planned therapy with another GP IIb/IIIa-receptor inhibitor.¹
Patients undergoing renal dialysis.¹
Known hypersensitivity to eptifibatide or any ingredient in the formulation.¹

Warnings/Precautions

Warnings

Bleeding

Risk of major bleeding (e.g., intracranial hemorrhage, GU or GI bleeding, bleeding at femoral vascular access site)¹ ⁸ ¹⁷ ⁷¹ ⁸⁵ ¹¹⁷ and minor bleeding (e.g., spontaneous gross hematuria, spontaneous hematemesis);¹ ⁸ ¹⁷ ⁷² ⁸⁵ may require blood or platelet transfusions.¹ ¹⁰ ¹¹⁷ (See Bleeding Precautions and see Laboratory Monitoring under Cautions.) Patients weighing <70 kg at increased risk of major bleeding.¹

If bleeding cannot be controlled by pressure, discontinue eptifibatide and concomitant heparin immediately.¹

Use not recommended in patients with hematocrit <30%.⁸ ⁷²

Thrombocytopenia

Thrombocytopenia reported.¹¹⁰ ¹¹¹ Severe thrombocytopenia (platelet count <20,000/mm³) reported less frequently than with abciximab.⁸ ²⁶ ⁴⁰ ⁵⁵ ⁷² ⁹³ ⁹⁹ ¹¹¹

Determine platelet counts prior to treatment and periodically (e.g., daily)⁷² during concomitant eptifibatide and heparin therapy.⁸ ⁷² ⁸⁸ Consider possibility of heparin-induced thrombocytopenia in patients receiving concomitant heparin therapy.²⁹ ⁵⁵ ⁹³ ¹⁰⁷ ¹¹¹

If platelet count decreases to <100,000/mm³, discontinue eptifibatide and heparin and initiate appropriate treatment and monitoring.¹ Consider platelet transfusions for management of severe thrombocytopenia.⁵⁵ ⁹³ ¹⁰⁶ ¹¹¹ ¹¹²

No clinical experience with eptifibatide in patients with platelet counts <100,000/mm³.¹

Sensitivity Reactions

Hypersensitivity Reactions

Anaphylaxis reported.¹

General Precautions

Bleeding Precautions

To reduce risk of bleeding, adhere to strict anticoagulation guidelines; use a short course of low-dose, weight-adjusted heparin; avoid vascular and other trauma; carefully manage vascular (e.g., femoral artery) access site; and monitor all potential bleeding sites during and following treatment.¹ ²⁶ ²⁹ ⁴³ ⁵² ⁹⁷ ¹⁰⁷ ¹⁰⁹ Manufacturer recommends that concomitant thrombolytic therapy be used with caution.¹

In patients undergoing PCI, use caution in the placement, maintenance, and removal of vascular access sheath.¹ ²⁶ ⁴⁴ ⁵² When inserting sheath, puncture only anterior wall of femoral artery; avoid Seldinger (through and through) technique.⁸ ²⁶ ⁷² Observe appropriate precautions while sheath is in place (e.g., complete bed rest, elevation of head ≤30°, restrain limb in which sheath is inserted, frequent monitoring of vascular access site and distal pulse in the involved limb).²⁶ ²⁷ ⁷² Following PCI, consider early sheath removal (during eptifibatide IV infusion).¹ Prior to removal of sheath, discontinue heparin for 3–4 hours and allow aPTT to return to <45 seconds or ACT to <150–180 seconds.¹ ²⁶ ²⁷ ³⁵ ⁴⁴ Discontinue eptifibatide and heparin and achieve hemostasis (by applying pressure to femoral artery for at least 20–30 minutes after sheath removal²⁶ ²⁷ ) at least 2–4 hours before hospital discharge.¹ Measure and monitor hematomas for enlargement.⁸ ²⁶ ⁷²

To avoid vascular and other trauma, minimize needle punctures (e.g., arterial, IM, IV, lumbar, sub-Q, intradermal), cutdown sites, and use of nasotracheal intubation, nasogastric tubes, urinary catheters, and automatic BP cuffs²⁶ during and following treatment;¹ ⁸ ⁷² avoid establishment of IV access at noncompressible sites (e.g., subclavian or jugular veins);¹ consider using an indwelling venipuncture device (e.g., heparin lock) for drawing blood; document and monitor vascular puncture sites; and remove dressings gently and carefully.⁸ ²⁶ ⁷²

Laboratory Monitoring

Prior to administration, obtain hematocrit or hemoglobin, platelet count, S_cr, and PT or aPTT.¹ In patients undergoing PCI, also obtain ACT prior to administration.¹

In patients with unstable angina or non-ST-segment-elevation MI undergoing medical management, target aPTT between 50–70 seconds.¹

In patients undergoing PCI the manufacturer recommends targeting ACT between 200–300 seconds during PCI.¹

Monitor aPTT or ACT prior to arterial sheath removal; do not remove sheath unless aPTT ≤45 seconds or ACT <150–180 seconds.¹ ²⁶ ²⁷ ³⁵ ⁴⁴

Specific Populations

Pregnancy

Category B.¹

Lactation

Not known whether eptifibatide is distributed into milk.¹ Use with caution.¹

Pediatric Use

Safety and efficacy not established.¹ ⁸

Geriatric Use

No substantial differences in efficacy relative to younger adults.¹ However, increased incidence of bleeding complications.¹

Hepatic Impairment

Use contraindicated in patients with hepatic disease severe enough to alter synthesis of coagulation factors.⁸

Renal Impairment

Decreased clearance and increased plasma concentrations in patients with moderate to severe renal impairment (estimated Cl_cr <50 mL/minute);¹ reduced dosage recommended in such patients.¹ (See Renal Impairment under Dosage and Administration.) Use contraindicated in patients undergoing renal dialysis.¹

Common Adverse Effects

Bleeding,¹ hypotension.¹ ⁸ ⁴³

Drug Interactions

Specific Drugs

Drug	Interaction	Comments
Anticoagulants, oral	Potential increased risk of bleeding¹	Use with caution¹
Dipyridamole	Potential increased risk of bleeding¹	Use with caution¹
Enoxaparin	Pharmacokinetic or pharmacodynamic (e.g., effect on platelet aggregation) interaction unlikely¹
GP IIb/IIIa-receptor inhibitors (abciximab, tirofiban)	Possible additive pharmacologic effects¹ ⁴	Avoid concomitant use¹ ⁴
Heparin	Possible additive effects on ACT¹⁹	Reduce dosage of heparin to maintain appropriate ACT¹⁹
NSAIAs	Potential increased risk of bleeding¹	Use with caution¹
Thrombolytics (e.g., alteplase, streptokinase)	Increased risk of bleeding, including that requiring blood transfusions¹ ⁵ ³⁴	Use with caution¹ ⁴ ³⁴ ⁴³ ⁷²

Eptifibatide Pharmacokinetics

Absorption

Bioavailability

Peak plasma concentrations achieved within 5 minutes and steady-state concentrations attained within 4–6 hours following IV administration.¹ ⁴ ⁹ ⁴¹ ⁴³

Onset

Maximal inhibition of platelet aggregation occurs within 15 minutes following IV administration and is rapidly reversible.¹ ⁸ ¹²

Duration

Platelet aggregation usually returns to normal within 4–8 hours after discontinuing therapy.⁸ ¹³ ³¹ ⁴¹ ⁴³

Special Populations

Steady-state plasma concentrations double in patients with moderate to severe renal impairment (estimated Cl_cr <50 mL/minute).¹

Increased plasma concentrations in geriatric patients.¹

Distribution

Extent

Not known whether eptifibatide is distributed into breast milk.¹

Plasma Protein Binding

Approximately 25% (mainly albumin).¹ ⁸ ⁴¹ ⁴³

Elimination

Metabolism

Principally metabolized to a less active metabolite;¹ ⁹ ⁴¹ ⁷¹ 27% of dose is converted in plasma into naturally occurring amino acids.⁴ ⁴¹

Elimination Route

Eliminated by renal (40–50% of total body clearance)¹ ⁸ ⁹ ⁷¹ and nonrenal mechanisms,⁹ ⁴¹ ⁴³ ⁷¹ mainly as parent drug and metabolites.¹ In healthy men, approximately 98, 1.5, and 0.8% of a single dose was recovered in urine, feces, and breath carbon dioxide, respectively.⁹

May be removed by hemodialysis.¹

Half-life

2.5–2.8 hours in patients with CAD;¹ ⁸ ¹⁹ 0.83–2.4 hours in healthy individuals.² ⁸ ⁴² ⁷¹

Special Populations

Clearance reduced by 50% in patients with moderate to severe renal impairment (estimated Cl_cr <50 mL/minute).¹

Reduced total body clearance in geriatric patients.¹

Stability

Storage

Parenteral

Injection

2–8°C.¹ ⁸ Protect from light.¹ ⁸

May store at room temperature (15–30°C) for ≤2 months.¹ ⁸

Compatibility

Parenteral

No incompatibilities observed with IV administration sets; no compatibility studies performed with polyvinyl chloride (PVC) bags.¹

Solution Compatibility1

*Infusion may contain up to 60 mEq/L of potassium chloride.¹

Compatible
Dextrose 5% and sodium chloride 0.9%*
Sodium chloride 0.9%*

Drug Compatibility1

Admixture CompatibilityHID
Compatible
Alteplase
Amiodarone HCl
Atropine
Bivalirudin
Dobutamine HCI
Heparin sodium
Lidocaine HCI
Meperidine HCI
Metoprolol tartrate
Midazolam HCI
Morphine sulfate
Nitroglycerin
Verapamil HCI
Incompatible
Furosemide

Actions

Binds selectively to platelet GP IIb/IIIa receptors and reversibly inhibits platelet aggregation (by preventing binding of fibrinogen, von Willebrand factor, and other adhesive ligands to GP IIb/IIIa receptors).¹ ² ³ ⁴ ⁷ ⁸ ¹⁶ ³⁷ ⁷¹
Modest effect on hemostatic indices (e.g., bleeding times) and platelet function; normal hemostasis restored more rapidly than with abciximab.¹ ² ⁶ ¹⁰ ¹⁷ ⁷²
Usually does not affect PT or aPTT when administered as monotherapy.¹

Advice to Patients

Risk of serious bleeding or hemorrhage.¹
Importance of close laboratory monitoring.¹
Importance of informing clinicians of existing or contemplated therapy, including prescription and OTC drugs and dietary or herbal supplements, as well as any concomitant illnesses.¹
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.¹
Importance of advising patients of other important precautionary information.¹ (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Eptifibatide
Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Parenteral	Injection, for IV Use	2 mg/mL (20 mg)	Integrilin	Schering
		0.75 mg/mL (75 mg)	Integrilin	Schering

† Off-label: Use is not currently included in the labeling approved by the US Food and Drug Administration.

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