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PRASUGREL
Indications
in combination with aspirin for the pre-
vention of atherothrombotic events in patients with
acute coronary syndrome undergoing percutaneous
coronary intervention
Cautions
patients at increased risk of bleeding (e.g.
from recent trauma,
surgery,
gastro-intestinal bleed-
ing, or active peptic ulcer disease); concomitant use of
drugs that increase risk of bleeding;
discontinue at
least 7 days before elective surgery if antiplatelet
effect not desirable;
elderly;
body-weight less than
60 kg;
interactions: Appendix 1 (prasugrel)
Contra-indications
active bleeding;
history of stroke
or transient ischaemic attack
Hepatic impairment
use with caution—increased risk
of bleeding;
avoid in severe impairment
Renal impairment
use with caution—increased risk
of bleeding
Pregnancy
manufacturer advises use only if potential
benefit outweighs risk
Breast-feeding
manufacturer advises avoid—no
information available
Side-effects
haemorrhage (including gastro-intestinal
and intracranial),
haematoma; haematuria; anaemia;
rash
Dose
.
ADULT
over 18 years, (with aspirin—see notes above)
initially 60 mg as a single dose then body-weight over
60 kg, 10 mg once daily
or
body-weight under 60 kg or
ELDERLY
over 75 years,
5 mg once daily
Efient
c
(Lilly) T A
Tablets
,
f/c,
prasugrel (as hydrochloride) 5 mg (yel-
low), net price 28-tab pack = £47.56;
10 mg (beige),
28-tab pack = £47.56
TIROFIBAN
Indications
prevention of early myocardial infarction
in patients with unstable angina or non-ST-segment-
elevation myocardial infarction and with last episode
of chest pain within 12 hours (use under specialist
supervision)
Cautions
major surgery or severe trauma within 3
months (avoid if within 6 weeks); traumatic or pro-
tracted cardiopulmonary resuscitation, organ biopsy
or lithotripsy within last 2 weeks; risk of bleeding
including active peptic ulcer within 3 months;
acute
pericarditis,
aortic dissection,
haemorrhagic retino-
pathy,
vasculitis,
haematuria, faecal occult blood;
severe heart failure,
cardiogenic shock,
anaemia;
puncture of non-compressible vessel within 24 hours;
concomitant drugs that increase risk of bleeding
(including within 48 hours of thrombolytic adminis-
tration);
monitor platelet count,
haemoglobin and
haematocrit before treatment, 2–6 hours after start of
treatment and then at least once daily;
discontinue if
thrombolytic therapy,
intra-aortic balloon pump or
emergency cardiac surgery necessary;
discontinue
immediately if serious bleeding uncontrolled by
pressure occurs;
interactions: Appendix 1 (tirofiban)
Contra-indications
abnormal bleeding within 30
days,
stroke within 30 days or any history of hae-
morrhagic stroke,
intracranial disease (aneurysm,
neoplasm or arteriovenous malformation),
severe
hypertension,
haemorrhagic diathesis,
increased
prothrombin time or INR,
thrombocytopenia
Hepatic impairment
caution in mild to moderate liver
disease;
avoid in severe liver disease—increased risk
of bleeding
Renal impairment
increased risk of bleeding; monitor
carefully if eGFR less than 60 mL/minute/1.73 m
2
;
use half normal dose if eGFR less than 30 mL/min-
ute/1.73 m
2
Pregnancy
manufacturer advises use only if potential
benefit outweighs risk—no information available
Breast-feeding
manufacturer advises avoid—no
information available
Side-effects
bleeding manifestations; reversible
thrombocytopenia
Dose
. By intravenous infusion,
initially 400 nanograms/kg/
minute for 30 minutes,
then 100 nanograms/kg/
minute for at least 48 hours (continue during and for
12–24 hours after percutaneous coronary interven-
tion);
max.
duration of treatment 108 hours
Aggrastat
c
(Chiesi) A
Concentrate for intravenous infusion
,
tirofiban (as
hydrochloride) 250 micrograms/mL.
For dilution
before use,
net price 50-mL (12.5-mg) vial = £146.11
Intravenous infusion
,
tirofiban (as hydrochloride)
50 micrograms/mL, net price 250-mL
Intravia
c
bag
= £160.72
2.10
Stable angina, acute
coronary syndromes, and
fibrinolysis
2.10.1 Management of stable angina and
acute coronary syndromes
2.10.2 Fibrinolytic drugs
2.10.1
Management of stable
angina and acute
coronary syndromes
Stable angina
It is important to distinguish stable angina from unstable
angina.
Stable angina
usually results from atherosclero-
tic plaques in the coronary arteries and is often pre-
cipitated by exertion and relieved by rest.
Treatment
involves management of acute anginal
pain,
and long-
term management
to prevent
angina attacks and to
reduce the risk of cardiovascular events.
Management of stable angina
Acute attacks of stable angina should be managed with
sublingual glyceryl trinitrate (section 2.6.1); sublingual
glyceryl
trinitrate can also be taken before performing
activities that are known to bring on an attack. If attacks
occur more than twice a week,
regular drug therapy is
required and should be introduced in a step-wise man-
ner according to response.
154
2.10 Stable angina, acute coronary syndromes, and fibrinolysis
BNF 61
2
Cardiovascular system