title: Prospective evaluation of a bivalirudin to warfarin transition nomogram.
abstract: Bivalirudin may cause a falsely prolonged international normalized ratio (INR) that complicates the discontinuation of bivalirudin when used as a bridge to warfarin. To prospectively validate our novel bivalirudin to warfarin transition nomogram, adult patients who received bivalirudin as a bridge to warfarin between July 2015 and June 2016 were prospectively evaluated, utilizing our predictive nomogram. The major outcome of our analysis was the correlation between the predicted change in INR upon bivalirudin discontinuation based on the nomogram, and the actual change in INR upon bivalirudin discontinuation. The major outcome was analyzed using the Pearson's correlation test. A Pearson's correlation coefficient >0.6 was considered to be a strong correlation. Bivalirudin was used as a bridge to warfarin in 29 patients. The majority of patients (86%) included in the analysis had a ventricular assist device. The median initial bivalirudin rate was 0.07 mg/kg/h and the mean increase in INR when starting bivalirudin was 0.6. The mean final weight-based bivalirudin rate was 0.08 mg/kg/h and the mean change in INR after stopping bivalirudin was 0.7. The Pearson correlation coefficient between the predicted change in INR upon bivalirudin discontinuation and the actual change in INR upon bivalirudin discontinuation was 0.86 (p < 0.001). After bivalirudin discontinuation, 68% of patients had a therapeutic INR. The results of this prospective analysis successfully validated our novel bivalirudin to warfarin transition nomogram. There was a very strong correlation between the predicted change and actual change in INR upon bivalirudin discontinuation.
authors.affiliation: Department of Pharmacy Services, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA. benhohlfelder@gmail.com.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Hohlfelder
authors.affiliation: Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Katelyn W
authors.initials: KW
authors.lastname: Sylvester
authors.affiliation: Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Jessica
authors.initials: J
authors.lastname: Rimsans
authors.affiliation: Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: David
authors.initials: D
authors.lastname: DeiCicchi
authors.affiliation: Hematology Division, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Jean M
authors.initials: JM
authors.lastname: Connors
mesh_terms: D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D005260:Female; D006353:Heart-Assist Devices; D006629:Hirudins / Q000008:administration & dosage*; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D049451:Nomograms; D010446:Peptide Fragments / Q000008:administration & dosage*; D011446:Prospective Studies; D011994:Recombinant Proteins / Q000008:administration & dosage; D014859:Warfarin / Q000008:administration & dosage*
chemical_list: D000925:Anticoagulants; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; D014859:Warfarin; C074619:bivalirudin
keywords: Bivalirudin; Direct thrombin inhibitor; International normalized ratio; Ventricular assist device; Warfarin