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    GP IIb/IIIa (glycoprotein) Antagonist Platelet Aggregation Inhibitors

    DEA CLASS

    Rx

    DESCRIPTION

    Platelet glycoprotein IIb/IIIa receptor antagonist
    Adjunctive therapy for preventing cardiac ischemic complications in percutaneous coronary intervention (PCI) or in patients with unresponsive unstable angina
    Fab fragment of the chimeric monoclonal antibody 7E3

    COMMON BRAND NAMES

    ReoPro

    HOW SUPPLIED

    ReoPro Intravenous Inj Sol: 1mL, 2mg

    DOSAGE & INDICATIONS

    For percutaneous coronary intervention (PCI) (e.g., angioplasty, atherectomy, stent placement).
    For use as an adjunct to percutaneous coronary intervention (PCI) for the prevention of cardiac ischemic complications, including prevention of myocardial infarction (i.e., myocardial infarction prophylaxis).
    Intravenous dosage
    Adults

    0.25 mg/kg IV bolus 10—60 minutes before the start of the PCI, followed by a continuous IV infusion of 0.125 mcg/kg/minute (Max: 10 mcg/minute) for 12 hours. Administer in combination with aspirin and heparin. If PCI fails, discontinue infusion of abciximab.

    For the prevention of cardiac ischemic complications in patients with acute myocardial infarction, NSTEMI or unstable angina (UA) not responding to conventional medical therapy when percutaneous coronary intervention (PCI) is planned within 24 hours.
    Intravenous dosage
    Adults

    0.25 mg/kg IV bolus followed by an 18—24 hour continuous IV infusion of 10 mcg/minute, concluding 1 hour after the PCI. Abciximab should be used in combination with aspirin (unless contraindicated) and heparin. If PCI fails, discontinue infusion of abciximab. Clinical practice guidelines support GP IIb/IIIa inhibitors at the time of PCI for patients with UA and NSTEMI with intermediate/high-risk features (e.g., positive troponin) treated with early invasive strategy and dual antiplatelet therapy; a GP IIb/IIIa inhibitor may be considered as part of initial antiplatelet therapy. This regimen is also recommended at the time of PCI for UA/NSTEMI patients with high-risk features (e.g., elevated troponin) who are receiving unfractionated heparin (UFH), not treated with bivalirudin, not adequately pretreated with ticagrelor, and regardless of clopidogrel pretreatment. For patients referred for coronary artery bypass graft surgery (CABG), discontinue abciximab at least 12 hours prior to surgery.

    For the prevention of cardiac ischemic complications in patients with ST-elevation MI (STEMI)† undergoing percutaneous coronary intervention (PCI).
    Intravenous dosage
    Adults

    0.25 mg/kg IV bolus at the time of PCI, followed by a continuous IV infusion of 0.125 mcg/kg/minute (Max: 10 mcg/minute) for 12 hours. Abciximab should be administered with aspirin (unless contraindicated) and heparin. Clinical practice guidelines support the adjunctive use of GP IIb/IIIa inhibitors at the time of primary PCI in select patients with STEMI (i.e., large thrombus burden or inadequate P2Y12 receptor antagonist loading) who are receiving unfractionated heparin (UFH) and treated with or without clopidogrel or stenting. If coronary artery bypass graft surgery (CABG) is planned, discontinue abciximab at least 12 hours prior to surgery.

    Intracoronary dosage†
    Adults

    0.25 mg/kg intracoronary bolus before PCI, followed by a continuous IV infusion of 0.125 mcg/kg/minute (Max: 10 mcg/minute) for 12 hours. Clinical practice guidelines consider intracoronary abciximab administration as reasonable in select STEMI cases.

    For the treatment of large coronary aneurysms with or without thrombus formation in children with Kawasaki disease†.
    Intravenous dosage
    Children†

    Limited data indicate that 0.25 mg/kg IV bolus followed by 0.125 mcg/kg/min continuous IV infusion for 12 hours in combination with standard treatment (IVIG plus aspirin) may be effective. In a retrospective review, patients treated with abciximab in addition to standard therapy (n=6) compared to patients treated with standard therapy alone (n=9) experienced a greater regression in maximal aneurysm diameter at 4—6 months after abciximab treatment (41% decrease with abciximab vs. 17% decrease with standard treatment only, p=0.003); additionally, complete resolution of the aneurysms occurred in 68% of patients treated with abciximab vs. 35% of patients treated with standard therapy alone (p=0.10). A single case report describes a similar 4 month old patient with a large coronary aneurysm plus thrombus who received standard therapy and abciximab in combination with heparin and high-dose aspirin; warfarin was initiated (goal INR 2.5—3) one day after the cardiac catheterization. The patient was discharged on low-dose aspirin plus warfarin. At 6 weeks, the aneurysm and thrombus were resolved; warfarin was discontinued, and aspirin was continued in combination with ticlopidine. The American Academy of Pediatrics and the American Heart Association indicate that abciximab can be considered in patients with large coronary aneurysms in the acute or subacute phase of Kawasaki disease, although prospective trials are needed (evidence level C).

    For the treatment of acute myocardial infarction, STEMI† secondary to coronary artery thrombosis in combination with reduced dose fibrinolytic therapy and heparin.
    NOTE: Although the ACCP antithrombotic guidelines recommend against this strategy for treating acute myocardial infarction (Grade 1B recommendation), the AHA-ACC STEMI guidelines suggest that abciximab combined with half-dose reteplase or tenecteplase may be considered to prevent complications of STEMI (e.g., reinfarction) in selected patients with anterior infarction location, age < 75 years, and no risk factors for bleeding (Class IIb recommendation).
    Intravenous dosage
    Adults

    The GUSTO V study evaluated reduced-dose reteplase (two 5 Unit boluses IV, given 30 min apart) in combination with full dose abciximab (0.25 mg/kg IV bolus, followed by 0.125 mcg/kg/min IV up to 10 mcg/min for 12 hours), in comparison to full dose reteplase alone (two 10 Unit boluses IV, given 30 min apart) in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. In comparison to full dose reteplase, the combined use of reduced-dose reteplase and abciximab demonstrated a similar 30 day mortality rate (met criteria for non-inferiority). The combination significantly reduced the overall MI complication rate by about 10% (31.7% vs. 28.6% frequency) including reinfarction, but was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In two prior angiographic trials (TIMI 14 and SPEED), the combined use of abciximab and reduced-dose fibrinolytic therapy enhanced early patency following acute MI. In the TIMI 14 study, 0.25 mg/kg IV bolus followed by a 12 hour continuous IV infusion of 0.125 mcg/kg/min in combination with alteplase (15 mg IV bolus, then 35 mg IV over 60 minutes) and very low dose heparin (30 units/kg IV bolus then 4 units/kg/hour continuous IV infusion) resulted in TIMI grade III flow rates of 72% and 77% at 60 and 90 minutes, respectively. These rate are significantly higher than those seen with alteplase alone (43% and 62%, respectively). The rate of major hemorrhage of this combination was 1%. The GUSTO IV pilot study (SPEED, Strategies for Patency Enhancement in the Emergency Department) evaluated abciximab, reteplase (5 units IV, repeated in 30 minutes), and low dose heparin and found that this combination also improved reperfusion rates. This study used reduced doses of reteplase (5 Unit double bolus) with full dose abciximab that resulted in 86% of patients achieving TIMI grade III flow at 90 minutes. Similarly, in the ASSENT-3 study, combination therapy with half-dose tenecteplase (15—30 mg IV bolus depending on weight), abciximab (0.25 mcg/kg IV bolus followed by 0.125 mcg/kg/min IV up to a max of 10 mcg/min IV) for 12 hours, and low-dose heparin (40 units/kg IV bolus to a max of 3000 units followed by 7 units/kg/hr to a max of 800 units/hr) was associated with a lower rate of the composite endpoint of 30-day mortality, in-hospital reinfarction, or in-hospital refractory ischemia compared to full-dose tenecteplase plus standard heparin therapy (11.1% for abciximab combination therapy vs. 15.4% for tenecteplase-heparin therapy, RR 0.72, 95% CI 0.61—0.84, p < 0.0001). Additionally, while intracranial hemorrhage occurred at a similar rate in both groups, the incidence of major hemorrhage other than intracranial hemorrhage was significantly higher in the abciximab combination therapy group (4.3% vs. 2.2%, p = 0.0005). Mortality at 1-year was similar between the 2 groups.

    Geriatric >= 75 years

    Combination therapy with abciximab and reduced dose thrombolytic therapy (e.g., reteplase or tenecteplase) is not recommended due to an increased risk of intracranial hemorrhage (ICH) (Class III recommendation).

    †Indicates off-label use

    MAXIMUM DOSAGE

    Adults

    0.25 mg/kg IV bolus; 10 mcg/min continuous IV infusion.

    Geriatric

    0.25 mg/kg IV bolus; 10 mcg/min continuous IV infusion.

    Adolescents

    Safety and efficacy have not been established.

    Children

    Safety and efficacy have not been established; 0.25 mg/kg IV bolus, followed by 0.125 mcg/kg/minute continuous IV infusion has been studied.

    DOSING CONSIDERATIONS

    Hepatic Impairment

    Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

    Renal Impairment

    Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

    ADMINISTRATION

    Injectable Administration

    Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.

    Intravenous Administration

    Do not shake vials containing abciximab.
     
    Intravenous bolus injection:
    Using aseptic technique, withdraw the necessary amount of abciximab for bolus injection into a syringe. Filter the bolus injection using a sterile, non-pyrogenic, low protein-binding 0.2 or 5 micrometer syringe filter (Millipore SLGV025LS or SLSV025LS or equivalent).
    Discard any unused portion left in the vial.
     
    Continuous IV infusion:
    Abciximab should be infused through a separate line whenever possible; do not add other medications to infusion solution.
    The solution for continuous infusion should be filtered either upon admixture using a sterile, non-pyrogenic, low protein-binding 0.2 or 5 micrometer syringe filter or upon administration using an in-line, sterile, non-pyrogenic, low protein-binding 0.2 or 0.22 micrometer filter.
    To prepare the continuous infusion, follow aseptic technique and withdraw the necessary amount of abciximab into a syringe. Inject into 250 mL of 0.9% Sodium Chloride Injection or 5% Dextrose Injection. A common dilution is 9 mg (4.5 mL) in 250 mL of 0.9% Sodium Chloride Injection or 5% Dextrose Injection to produce a final concentration of 36 mcg/mL. Infuse at the calculated rate via a continuous infusion pump. Discard unused solution at the end of the infusion.

    Other Injectable Administration

    Intracoronary Administration
    After infarct-related artery recanalization by percutaneous coronary intervention (PCI) wire and before balloon dilation, inject bolus over 1 minute via PCI guiding catheter directly into the lesion site.

    STORAGE

    ReoPro:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    - Do not freeze
    - Refrigerate (between 36 and 46 degrees F)

    CONTRAINDICATIONS / PRECAUTIONS

    Aneurysm, anticoagulant therapy, arteriovenous malformation, bleeding, coagulopathy, dextran therapy, GI bleeding, hypertension, intracranial mass, intramuscular injections, stroke, surgery, thrombocytopenia, thrombolytic therapy, trauma, vasculitis, venipuncture

    Inhibition of platelet aggregation by abciximab increases the risk of bleeding, especially in patients with predisposing conditions. Abciximab is contraindicated in patients with any of the following: intracranial aneurysm, intracranial mass, arteriovenous malformation, any coagulopathy or bleeding diathesis, recent (within 6 weeks) GI bleeding or genitourinary bleeding of clinical significance, severe uncontrolled hypertension, recent (within 6 weeks) major surgery or trauma, vasculitis, stroke within the last 2 years, or stroke with a significant residual neurological deficit. Abciximab is contraindicated in patients with thrombocytopenia (platelets less than 100,000 cells/mm3). Monitor platelet counts before abciximab treatment, 2 to 4 hours after the bolus dose, and at 24 hours or before discharge, whichever is first. If a patient experiences an acute decrease in platelet count (to less than 100,000 cells/mm3 and a decrease of at least 25% from baseline), additional platelet counts should be determined to rule out pseudothrombocytopenia. If thrombocytopenia is verified, immediately discontinue abciximab. Consider platelet transfusions if the platelet count decreases below 50,000 cells/mm3. Abciximab is also contraindicated when IV dextran therapy has been used before or will be used during percutaneous coronary intervention (PCI), or if oral anticoagulant therapy has been administered within 7 days unless the prothrombin time is 1.2 times or less the control. Abciximab may increase the risk of bleeding, including rare cases of fatal bleeding, particularly in patients receiving heparin, other anticoagulants, or thrombolytics. In patients receiving thrombolytic therapy, weigh the risk of major bleeding due to concomitant use of abciximab against the anticipated benefits. If serious bleeding occurs that cannot be controlled with pressure, discontinue abciximab and any concomitant heparin. The risk of bleeding with abciximab can be reduced if the following precautions are taken: use of low-dose, weight-adjusted heparin regimens, discontinuation of heparin immediately upon completion of the procedure, adherence to strict anticoagulation guidelines, early femoral arterial sheath removal (within 6 hours of the intervention if the APTT is 50 seconds or less or the ACT is 175 seconds or less) followed by at least 30 minutes of pressure to the femoral artery, careful patient and access site management, and weight-adjustment of the abciximab infusion dose. Minimize venipuncture, arterial puncture, intramuscular injections, use of urinary catheters, nasogastric tubes, and nasotracheal intubation. Maintain patients on complete bed rest (for 6 to 8 hours after sheath removal or discontinuation of abciximab, or 4 hours after discontinuation of heparin, whichever is later) with the head of the bed 30 degrees or less and the affected limb restrained in a straight position.[29816]

    Human anti-murine antibody (HAMA), murine protein hypersensitivity

    Abciximab is contraindicated in patients with known murine protein hypersensitivity. Abciximab contains the Fab fragment of a chimeric human-murine monoclonal antibody and may result in human anti-murine antibody (HAMA) formation.

    Abciximab hypersensitivity, human anti-chimeric antibody (HACA)

    Abciximab is contraindicated in patients with known abciximab hypersensitivity or hypersensitivity to any component of this product or to murine proteins. In addition, abciximab should be used with caution in patients who have previously received this drug. Administration of abciximab can result in the formation of human anti-chimeric antibody (HACA), which can potentially cause thrombocytopenia or abciximab hypersensitivity, including anaphylaxis, upon readministration. If symptoms of an allergic reaction or anaphylaxis appear, the infusion should be stopped and appropriate treatment given. Patients with HACA titers can also have an allergic response to other monoclonal antibodies.

    Pregnancy

    Animal reproduction studies have not been conducted with abciximab, and it is unknown if abciximab can cause fetal harm when administered during pregnancy or if it can affect reproduction capacity. Use abciximab during pregnancy only if clearly needed.[29816]

    Breast-feeding

    It is unknown whether abciximab is excreted into breast milk or absorbed systemically after ingestion. Because many drugs are excreted in human milk, use caution when administering abciximab to a woman who is breast-feeding.[29816]

    Children, infants

    Safety and efficacy of abciximab in children and infants have not been established; however, limited data indicate that abciximab in combination with standard treatment (IVIG plus aspirin) may be effective in treating large coronary artery aneurysms in patients with Kawasaki disease (KD) (see Dosage). The American Academy of Pediatrics and the American Heart Association indicate that abciximab can be considered in pediatric patients with large coronary aneurysms in the acute or subacute phase of KD, although prospective trials are needed (evidence level C).

    Geriatric

    Phase III trial experience with abciximab has not identified differences in responses in safety or efficacy between geriatric and younger patients. Of the total number of 7,860 patients in the four Phase 3 trials, 2,933 (37%) were 65 and over, while 653 (8%) were 75 and over. The manufacturer notes that clinical experience has not been adequate to determine whether elderly patients over 75 years respond differently than younger adult patients. For some clinical indications, use of abciximab in geriatric patients over 75 years is not recommended.

    ADVERSE REACTIONS

    Severe

    bleeding / Early / 0.8-10.6
    bradycardia / Rapid / 4.5-4.5
    thrombocytopenia / Delayed / 0.4-1.7
    ventricular tachycardia / Early / 1.4-1.4
    stroke / Early / 0.3-0.3
    AV block / Early / 0.1-0.3
    bronchospasm / Rapid / 0.3-0.3
    pleural effusion / Delayed / 0.3-0.3
    visual impairment / Early / 0.3-0.3
    coma / Early / 0.2-0.2
    pulmonary embolism / Delayed / 0.2-0.2
    intracranial bleeding / Delayed / 0.1-0.1
    thromboembolism / Delayed / 0.1-0.1
    hyperkalemia / Delayed / 0.1-0.1
    ileus / Delayed / 0.1-0.1
    retroperitoneal bleeding / Delayed / Incidence not known
    GI bleeding / Delayed / Incidence not known
    hematemesis / Delayed / Incidence not known
    anaphylactoid reactions / Rapid / Incidence not known
    anaphylactic shock / Rapid / Incidence not known

    Moderate

    antibody formation / Delayed / 5.8-27.0
    hypotension / Rapid / 14.4-14.4
    chest pain (unspecified) / Early / 11.4-11.4
    peripheral edema / Delayed / 1.6-1.6
    anemia / Delayed / 1.3-1.3
    urinary retention / Early / 0.7-0.7
    palpitations / Early / 0.5-0.5
    confusion / Early / 0.5-0.5
    dysuria / Early / 0.4-0.4
    hypertonia / Delayed / 0.2-0.2
    phlebitis / Rapid / 0.1-0.1
    urinary incontinence / Early / 0.1-0.1
    prostatitis / Delayed / 0.1-0.1
    bullous rash / Early / 0.1-0.1
    diabetes mellitus / Delayed / 0.1-0.1
    hematuria / Delayed / Incidence not known
    prolonged bleeding time / Delayed / Incidence not known
    platelet dysfunction / Delayed / Incidence not known
    hemoptysis / Delayed / Incidence not known

    Mild

    back pain / Delayed / 17.6-17.6
    nausea / Early / 13.6-13.6
    vomiting / Early / 7.3-7.3
    headache / Early / 6.4-6.4
    injection site reaction / Rapid / 0.1-3.6
    abdominal pain / Early / 3.1-3.1
    dizziness / Early / 2.9-2.9
    dyspepsia / Early / 2.1-2.1
    anxiety / Delayed / 1.7-1.7
    diarrhea / Early / 1.1-1.1
    hyperhidrosis / Delayed / 1.0-1.0
    asthenia / Delayed / 0.7-0.7
    agitation / Early / 0.7-0.7
    hypoesthesia / Delayed / 0.6-0.6
    leukocytosis / Delayed / 0.5-0.5
    pruritus / Rapid / 0.5-0.5
    petechiae / Delayed / 0.2-0.2
    myalgia / Early / 0.2-0.2
    pallor / Early / 0.1-0.1
    gastroesophageal reflux / Delayed / 0.1-0.1
    xerostomia / Early / 0.1-0.1
    increased urinary frequency / Early / 0.1-0.1
    diplopia / Early / 0.1-0.1

    DRUG INTERACTIONS

    Acetaminophen; Aspirin, ASA; Caffeine: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Ado-Trastuzumab emtansine: (Moderate) Use caution if coadministration of platelet inhibitors with ado-trastuzumab emtansine is necessary due to reports of severe and sometimes fatal hemorrhage, including intracranial bleeding, with ado-trastuzumab emtansine therapy. Consider additional monitoring when concomitant use is medically necessary. While some patients who experienced bleeding during ado-trastuzumab therapy were also receiving anticoagulation therapy, others had no known additional risk factors.
    ADP receptor antagonists: (Moderate) Concomitant use of platelet glycoprotein IIb/IIIa inhibitors (i.e., abciximab, eptifibatide, or tirofiban) with an ADP receptor antagonist (i.e., clopidogrel, prasugrel, ticagrelor, or ticlopidine) may be associated with an increased risk of bleeding.
    Altretamine: (Moderate) An additive risk of bleeding may occur when platelet inhibitors is used with agents that cause clinically significant thrombocytopenia including antineoplastic agents, such as altretamine.
    Aminolevulinic Acid: (Minor) Agents, such as platelet inhibitors, that decrease clotting could decrease the efficacy of photosensitizing agents used in photodynamic therapy.
    Anagrelide: (Moderate) Although anagrelide inhibits platelet aggregation at high doses, there is a potential additive risk for bleeding if anagrelide is given in combination with other agents that effect hemostasis such as platelet glycoprotein IIb/IIIa inhibitors including abciximab, eptifibatide, and tirofiban.
    Antimetabolites: (Moderate) An additive risk of bleeding may occur when platelet inhibitors are used with agents that cause clinically significant thrombocytopenia including antimetabolites.
    Antithrombin III: (Moderate) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.
    Antithymocyte Globulin: (Moderate) An increased risk of bleeding may occur when platelet inhibitors are used with agents that cause clinically significant thrombocytopenia, such as antithymocyte globulin. Platelet inhibitors should be used cautiously in patients with thrombocytopenia following the administration of antithymocyte globulin or other drugs that cause significant thrombocytopenia due to the increased risk of bleeding.
    Apixaban: (Major) The concomitant use of apixaban and platelet inhibitors (e.g, aspirin) may increase the risk of bleeding. In the ARISTOTLE trial (comparative trial of apixaban and warfarin in patients with nonvalvular atrial fibrillation), concomitant use of aspirin increased the bleeding risk of apixaban from 1.8%/year to 3.4%/year. If given concomitantly, patients should be educated about the signs and symptoms of bleeding and be instructed to report them immediately or go to an emergency room.
    Argatroban: (Moderate) An additive risk of bleeding may be seen in patients receiving platelet inhibitors (e.g., clopidogrel, platelet glycoprotein IIb/IIIa inhibitors, ticlopidine, etc.) in combination with argatroban.
    Arsenic Trioxide: (Moderate) Abciximab is contraindicated for use in patients with a platelet count of less than 100,000 cells/microliter. Patients with thrombocytopenia are at increased risk of bleeding complications. Thus, antineoplastic agents that cause clinically significant thrombocytopenia could increase the bleeding risk associated with abciximab. An additive risk of bleeding may occur when abciximab is used with agents that cause clinically significant thrombocytopenia.
    Aspirin, ASA: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Butalbital; Caffeine: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Butalbital; Caffeine; Codeine: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Caffeine; Dihydrocodeine: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Caffeine; Orphenadrine: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Carisoprodol: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Carisoprodol; Codeine: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Citric Acid; Sodium Bicarbonate: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Dipyridamole: (Moderate) Because dipyridamole is a platelet inhibitor, there is a potential additive risk for bleeding if dipyridamole is given in combination with other agents that affect hemostasis such as platelet glycoprotein IIb/IIIa inhibitors including abciximab, eptifibatide, and tirofiban. (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Omeprazole: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Oxycodone: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Aspirin, ASA; Pravastatin: (Moderate) Unless contraindicated, aspirin is used in combination with abciximab. However, both drugs are associated with bleeding. Monitor for bleeding during concomitant therapy.
    Betrixaban: (Major) Monitor patients closely and promptly evaluate any signs or symptoms of bleeding if betrixaban and platelet inhibitors are used concomitantly. Coadministration of betrixaban and platelet inhibitors may increase the risk of bleeding.
    Bexarotene: (Moderate) An additive risk of bleeding may occur when platelet inhibitors are used with agents that cause clinically significant thrombocytopenia including bexarotene.
    Bivalirudin: (Moderate) When used as an anticoagulant in patients undergoing percutaneous coronary intervention (PCI), bivalirudin is intended for use with aspirin (300 to 325 mg/day PO) and has been studied only in patients receiving concomitant aspirin. Generally, an additive risk of bleeding may be seen in patients receiving other platelet inhibitors (other than aspirin). In clinical trials in patients undergoing PTCA, patients receiving bivalirudin with heparin, warfarin, or thrombolytics had increased risks of major bleeding events compared to those receiving bivalirudin alone. According to the manufacturer, the safety and effectiveness of bivalirudin have not been established when used in conjunction with platelet inhibitors other than aspirin. However, bivalirudin has been safely used as an alternative to heparin in combination with provisional use of platelet glycoprotein IIb/IIIa inhibitors during angioplasty (REPLACE-2). In addition, two major clinical trials have evaluated the use of bivalirudin in patients receiving streptokinase following acute myocardial infarction (HERO-1, HERO-2). Based on the these trials, bivalirudin may be considered an alternative to heparin therapy for use in combination with streptokinase for ST-elevation MI. Bivalirudin has not been sufficiently studied in combination with other more specific thrombolytics.
    Chlorambucil: (Moderate) An additive risk of bleeding may occur when platelet inhibitors are used with agents that cause clinically significant thrombocytopenia including antineoplastic agents, such as chlorambucil.
    Cilostazol: (Moderate) Because cilostazol is a platelet aggregation inhibitor, a potential additive risk for bleeding exists if cilostazol is given with other agent that affect hemostasis such as platelet glycoprotein IIb/IIIa inhibitors including abciximab, eptifibatide, and tirofiban.
    Cladribine: (Moderate) Due to the thrombocytopenic effects of purine analogs, an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors.
    Clofarabine: (Moderate) Due to the thrombocytopenic effects of antineoplastics an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors.
    Collagenase: (Moderate) Cautious use of injectable collagenase by patients taking platelet inhibitors is advised. The efficacy and safety of administering injectable collagenase to a patient taking a platelet inhibitor within 7 days before the injection are unknown. Receipt of injectable collagenase may cause an ecchymosis or bleeding at the injection site.
    Dabigatran: (Moderate) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.
    Dalteparin: (Moderate) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.
    Danaparoid: (Moderate) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.
    Danazol: (Moderate) Danazol can decrease hepatic synthesis of procoagulant factors, increasing the possibility of bleeding when used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents.
    Dasatinib: (Moderate) Due to the thrombocytopenic and possible platelet inhibiting effects of dasatinib, an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors. Abciximab is contraindicated for use in patients with a platelet count of less than 100,000 cells/microliters. Patients with thrombocytopenia are at increased risk of bleeding complications. Thus, antineoplastic agents that cause clinically significant thrombocytopenia could increase the bleeding risk associated with abciximab.
    Defibrotide: (Severe) Coadministration of defibrotide with antithrombotic agents like platelet inhibitors is contraindicated. The pharmacodynamic activity and risk of hemorrhage with antithrombotic agents are increased if coadministered with defibrotide. If therapy with defibrotide is necessary, discontinue antithrombotic agents prior to initiation of defibrotide therapy. Consider delaying the onset of defibrotide treatment until the effects of the antithrombotic agent have abated.
    Denileukin Diftitox: (Moderate) An additive risk of bleeding may occur when platelet inhibitors are used with agents that cause clinically significant thrombocytopenia including antineoplastic agents, such as denileukin difitox.
    Desirudin: (Major) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.
    Desvenlafaxine: (Moderate) Platelet aggregation may be impaired by serotonin norepinephrine reuptake inhibitors (SNRIs) like desvenlafaxine due to platelet serotonin depletion, possibly increasing the risk of a bleeding complication in patients receiving abciximab. Monitor the patient closely for signs and symptoms of bleeding.
    Dipyridamole: (Moderate) Because dipyridamole is a platelet inhibitor, there is a potential additive risk for bleeding if dipyridamole is given in combination with other agents that affect hemostasis such as platelet glycoprotein IIb/IIIa inhibitors including abciximab, eptifibatide, and tirofiban.
    Drotrecogin Alfa: (Major) Treatment with drotrecogin alfa should be carefully considered in patients who are receiving or have received any platelet inhibitors within 7 days. These patients are at increased risk of bleeding during drotrecogin alfa therapy.
    Duloxetine: (Moderate) Platelet aggregation may be impaired by serotonin norepinephrine reuptake inhibitors (SNRIs) like duloxetine due to platelet serotonin depletion, possibly increasing the risk of a bleeding complication in patients receiving abciximab. Monitor the patient closely for signs and symptoms of bleeding.
    Edoxaban: (Major) Coadministration of edoxaban and platelet inhibitors should be avoided due to an increased risk of bleeding during concurrent use. Occasionally, short-term coadministration may be necessary in patients transitioning to and from edoxaban. Long-term coadminstration is not recommended. Promptly evaluate any signs or symptoms of blood loss in patients on concomitant therapy.
    Enoxaparin: (Moderate) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.
    Estramustine: (Moderate) An additive risk of bleeding may occur when platelet inhibitors are used with agents that cause clinically significant thrombocytopenia including antineoplastic agents, such as estramustine.
    Fish Oil, Omega-3 Fatty Acids (Dietary Supplements): (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with other platelet inhibitors. Theoretically, the risk of bleeding may be increased.
    Fludarabine: (Moderate) Due to the thrombocytopenic effects of purine analogs, an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors.
    Folate analogs: (Moderate) Due to the thrombocytopenic effects of folate analogs, when used as antineoplastic agents, an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors.
    Fondaparinux: (Moderate) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.
    Garlic, Allium sativum: (Moderate) Use together with caution. Garlic produces clinically significant antiplatelet effects, and a risk for bleeding may occur if platelet inhibitors are given in combination with garlic.
    Ginger, Zingiber officinale: (Moderate) Ginger inhibits thromboxane synthetase, a platelet aggregation inducer, and is a prostacyclin agonist so additive bleeding may occur if platelet inhibitors are given in combination with ginger, zingiber officinale.
    Ginkgo, Ginkgo biloba: (Major) Use Ginkgo biloba with caution in patients taking platelet inhibitors, as it can produce clinically-significant antiplatelet effects. A compound found in Ginkgo biloba, ginkgolide-B, may act as a selective antagonist of platelet activating factor (PAF). Although a review of Ginkgo biloba in 1992 stated that no known drug interactions exist, spontaneous hyphema has been reported in an elderly male who began taking Ginkgo while stabilized on daily aspirin. After ginkgo was stopped, no further bleeding was noted despite continuing the aspirin therapy. Other clinical data exist that describe spontaneous subdural hematomas associated with chronic Ginkgo biloba ingestion.
    Green Tea: (Moderate) Green tea has demonstrated antiplatelet and fibrinolytic actions in animals. It is possible that the use of green tea may increase the risk of bleeding if coadministered with abciximab. Caution and careful monitoring of clinical and/or laboratory parameters are warranted with this combination.
    Heparin: (Moderate) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.
    Ibritumomab Tiuxetan: (Major) During and after therapy, avoid the concomitant use of Yttrium (Y)-90 ibrutumomab tiuxetan with drugs that interfere with platelet function such as platelet inhibitors; the risk of bleeding may be increased. If coadministration with platelet inhibitors is necessary, monitor platelet counts more frequently for evidence of thrombocytopenia.
    Ibrutinib: (Moderate) The concomitant use of ibrutinib and antiplatelet agents such as abciximab may increase the risk of bleeding; monitor patients for signs of bleeding. Severe bleeding events have occurred with ibrutinib therapy including intracranial hemorrhage, GI bleeding, hematuria, and post procedural hemorrhage; some events were fatal. The mechanism for bleeding with ibrutinib therapy is not well understood.
    Icosapent ethyl: (Moderate) Icosapent ethyl is an ethyl ester of the omega-3 fatty acid eicosapentaenoic acid (EPA). Because omega-3 fatty acids inhibit platelet aggregation, caution is advised when icosapent ethyl is used concurrently with anticoagulants, platelet inhibitors, or thrombolytic agents. Theoretically, the risk of bleeding may be increased, but some studies that combined these agents did not produce clinically significant bleeding events. In one placebo-controlled, randomized, double-blinded, parallel study, patients receiving stable, chronic warfarin therapy were administered various doses of fish oil supplements to determine the effect on INR determinations. Patients were randomized to receive a 4-week treatment period of either placebo or 3 or 6 grams of fish oil daily. Patients were followed on a twice-weekly basis for INR determinations and adverse reactions. There was no statistically significant difference in INRs between the placebo or treatment period within each group. There was also no difference in INRs found between groups. One episode of ecchymosis was reported, but no major bleeding episodes occurred. The authors concluded that fish oil supplementation in doses of 36 grams per day does not have a statistically significant effect on the INR of patients receiving chronic warfarin therapy. However, an increase in INR from 2.8 to 4.3 in a patient stable on warfarin therapy has been reported when increasing the dose of fish oil, omega-3 fatty acids from 1 gram/day to 2 grams/day. The INR decreased once the patient decreased her dose of fish oil to 1 gram/day. This implies that a dose-related effect of fish oil on warfarin may be possible. Patients receiving warfarin that initiate concomitant icosapent ethyl therapy should have their INR monitored more closely and the dose of warfarin adjusted accordingly.
    Iloprost: (Moderate) When used concurrently with platelet inhibitors, inhaled iloprost may increase the risk of bleeding.
    Imatinib: (Moderate) Due to the thrombocytopenic effects of imatinib an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors.
    Inotersen: (Moderate) Use caution with concomitant use of inotersen and platelet glycoprotein IIb/IIIa inhibitors due to the potential risk of bleeding from thrombocytopenia. Consider discontinuation of platelet glycoprotein IIb/IIIa inhibitors in a patient taking inotersen with a platelet count of less than 50,000 per microliter.
    Intravenous Lipid Emulsions: (Moderate) Because fish oil, omega-3 fatty acids inhibit platelet aggregation, caution is advised when fish oils are used concurrently with other platelet inhibitors. Theoretically, the risk of bleeding may be increased.
    Lepirudin: (Moderate) An additive risk of bleeding may be seen in patients receiving platelet inhibitors (e.g., clopidogrel, platelet glycoprotein IIb/IIIa inhibitors, ticlopidine, etc.) in combination with lepirudin.
    Levomilnacipran: (Moderate) Carefully monitor patients for signs and symptoms of bleeding during coadministration of levomilnacipran and platelet inhibitors. Serotonin-norepinephrine reuptake inhibitors (SNRIs) affect platelet activation; therefore, concomitant use may increase the risk of bleeding.
    Lomustine, CCNU: (Moderate) An additive risk of bleeding may occur when platelet inhibitors are used with agents that cause clinically significant thrombocytopenia including antineoplastic agents, such as lomustine.
    Mercaptopurine, 6-MP: (Moderate) Due to the thrombocytopenic effects of purine analogs, an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors.
    Methoxsalen: (Minor) Agents that affect platelet function, such as platelet inhibitors, could decrease the efficacy of methoxsalen when used during photodynamic therapy.
    Methylsulfonylmethane, MSM: (Moderate) Increased effects from concomitant anticoagulant drugs including increased bruising or blood in the stool have been reported in patients taking methylsulfonylmethane, MSM. Although these effects have not been confirmed in published medical literature or during clinical studies, clinicians should consider using methylsulfonylmethane, MSM with caution in patients who are taking anticoagulants or antiplatelets including clopidogrel until data confirming the safety of these drug combinations are available. During one of the available, published clinical trials in patients with osteoarthritis, those patients with bleeding disorders or using anticoagulants or antiplatelets were excluded from enrollment. Patients who choose to consume methylsulfonylmethane, MSM while receiving clopidogrel should be observed for increased bleeding.
    Milnacipran: (Moderate) Carefully monitor patients for signs and symptoms of bleeding during coadministration of milnacipran and platelet inhibitors. Serotonin-norepinephrine reuptake inhibitors (SNRIs) affect platelet activation; therefore, concomitant use may increase the risk of bleeding.
    Mycophenolate: (Moderate) Platelet Inhibitors inhibit platelet aggregation and should be used cautiously in patients with thrombocytopenia, as mycophenolate can also cause thrombocytopenia.
    Nelarabine: (Moderate) Due to the thrombocytopenic effects of nelarabine, an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors.
    Nonsteroidal antiinflammatory drugs: (Moderate) NSAIDs can cause GI bleeding, inhibit platelet aggregation, and prolong bleeding time. If NSAIDs are administered with platelet inhibitors, these pharmacodynamic effects may be increased. The manufacturer of clopidogrel advises that caution be used when used in combination with NSAIDs as an increase in occult GI blood loss occurred when clopidogrel was used concomitantly with naproxen
    Obinutuzumab: (Moderate) Fatal hemorrhagic events have been reported in patients treated with obinutuzumab; all events occured during cycle 1. Monitor all patients for thrombocytopenia and bleeding, and consider withholding concomitant medications which may increase bleeding risk (i.e., anticoagulants, platelet inhibitors), especially during the first cycle.
    Pegaspargase: (Moderate) Due to the risk of bleeding and coagulopathy during pegaspargase therapy, patients should receive other agents that may increase the risk of bleeding (e.g., anticoagulants, NSAIDs, platelet inhibitors, or thrombolytic agents) with caution.
    Pentosan: (Moderate) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.
    Pentostatin: (Moderate) Due to the thrombocytopenic effects of purine analogs, an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors.
    Pentoxifylline: (Moderate) A potential additive risk for bleeding exists if platelet inhibitors are given in combination with other agents that affect hemostasis such as pentoxifylline.
    Phentermine; Topiramate: (Moderate) Concurrent use of topiramate and drugs that affect platelet function such as aspirin, ASA and other salicylates or platelet inhibitors may increase the risk of bleeding. In a pooled analysis of placebo-controlled trials, bleeding was more frequently reported in patients receiving topiramate (4.5%) compared to placebo (2-3%). In those with severe bleeding events, patients were often taking drugs that cause thrombocytopenia or affect platelet function or coagulation.
    Photosensitizing agents (topical): (Minor) Agents, such as platelet inhibitors, that decrease clotting could decrease the efficacy of photosensitizing agents used in photodynamic therapy.
    Photosensitizing agents: (Minor) Agents, such as platelet inhibitors, that decrease clotting could decrease the efficacy of photosensitizing agents used in photodynamic therapy.
    Porfimer: (Minor) Agents, such as platelet inhibitors, that decrease clotting could decrease the efficacy of photosensitizing agents used in photodynamic therapy.
    Prasterone, Dehydroepiandrosterone, DHEA (Dietary Supplements): (Moderate) Prasterone is contraindicated for use in patients with active deep vein thrombosis, pulmonary embolism or history of these conditions. Prasterone is also contraindicated in patients with active arterial thromboembolic disease (for example, stroke and myocardial infarction), or a history of these conditions. Thus, patients receiving anticoagulation due to a history of these conditions are not candidates for prasterone treatment. DHEA is converted to androgens and estrogens within the human body and thus may affect hemostasis via androgenic or estrogenic effects. Estrogens increase the production of clotting factors VII, VIII, IX, and X. Androgens, such as testosterone, increase the synthesis of several anticoagulant and fibrinolytic proteins. Because of the potential effects on coagulation, patients receiving prasterone or DHEA concurrently with preventative anticoagulants (e.g., warfarin or heparin) or other platelet inhibitors, including aspirin, ASA should be monitored for side effects or the need for dosage adjustments.
    Prasterone, Dehydroepiandrosterone, DHEA (FDA-approved): (Moderate) Prasterone is contraindicated for use in patients with active deep vein thrombosis, pulmonary embolism or history of these conditions. Prasterone is also contraindicated in patients with active arterial thromboembolic disease (for example, stroke and myocardial infarction), or a history of these conditions. Thus, patients receiving anticoagulation due to a history of these conditions are not candidates for prasterone treatment. DHEA is converted to androgens and estrogens within the human body and thus may affect hemostasis via androgenic or estrogenic effects. Estrogens increase the production of clotting factors VII, VIII, IX, and X. Androgens, such as testosterone, increase the synthesis of several anticoagulant and fibrinolytic proteins. Because of the potential effects on coagulation, patients receiving prasterone or DHEA concurrently with preventative anticoagulants (e.g., warfarin or heparin) or other platelet inhibitors, including aspirin, ASA should be monitored for side effects or the need for dosage adjustments.
    Purine analogs: (Moderate) Due to the thrombocytopenic effects of purine analogs, an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors.
    Rivaroxaban: (Major) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as anticoagulants. An increase in bleeding time to 45 minutes was observed in 2 drug interaction studies where another platelet inhibitor and rivaroxaban (15 mg single dose) were coadministered in healthy subjects. In the first study, the increase in bleeding time to 45 minutes was observed in approximately 45% of patients. Approximately 30% of patients in the second study had the event. The change in bleeding time was approximately twice the maximum increase seen with either drug alone. No change in the pharmacokinetic parameters of either drug were noted.
    Selective serotonin reuptake inhibitors: (Moderate) Platelet aggregation may be impaired by selective serotonin reuptake inhibitors (SSRIs) due to platelet serotonin depletion, possibly increasing the risk of a bleeding complication in patients receiving abciximab. Monitor closely for signs and symptoms of bleeding.
    Sodium Hyaluronate, Hyaluronic Acid: (Moderate) Increased bruising or bleeding at the injection site may occur when using hyaluronate sodium with platelet inhibitors especially if used within the 3 weeks prior to the procedure.
    Sulfinpyrazone: (Major) Sulfinpyrazone, when used as a uricosuric agent should be avoided when possible with concurrent platelet inhibitors due to potential for additive antiplatelet effects and increased bleeding risk.
    Thioguanine, 6-TG: (Moderate) Due to the thrombocytopenic effects of purine analogs, an additive risk of bleeding may be seen in patients receiving concomitant platelet inhibitors.
    Thrombolytic Agents: (Major) Concomitant administration of platelet inhibitors and thrombolytic agents could theoretically result in an increased risk of bleeding due to additive pharmacodynamic effects, and combinations of these agents should be approached with caution.
    Tinzaparin: (Moderate) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.
    Tipranavir: (Moderate) Caution should be used when administering tipranavir to patients receiving platelet inhibitors. In clinical trials, there have been reports of intracranial bleeding, including fatalities, in HIV infected patients receiving tipranavir as part of combination antiretroviral therapy. In many of these reports, the patients had other medical conditions (CNS lesions, head trauma, recent neurosurgery, coagulopathy, hypertension, or alcoholism/alcohol abuse) or were receiving concomitant medications, including platelet inhibitors, that may have caused or contributed to these events.
    Topiramate: (Moderate) Concurrent use of topiramate and drugs that affect platelet function such as aspirin, ASA and other salicylates or platelet inhibitors may increase the risk of bleeding. In a pooled analysis of placebo-controlled trials, bleeding was more frequently reported in patients receiving topiramate (4.5%) compared to placebo (2-3%). In those with severe bleeding events, patients were often taking drugs that cause thrombocytopenia or affect platelet function or coagulation.
    Trazodone: (Moderate) Platelet aggregation may be impaired by trazodone due to platelet serotonin depletion, possibly increasing the risk of a bleeding complication (e.g., gastrointestinal bleeding, ecchymoses, epistaxis, hematomas, petechiae, hemorrhage) in patients receiving platelet inhibitors (e.g., cilostazol, clopidogrel, dipyridamole, ticlopidine, platelet glycoprotein IIb/IIIa inhibitors). Patients should be instructed to monitor for signs and symptoms of bleeding while taking trazodone concurrently with an antiplatelet medication and to promptly report any bleeding events to the practitioner.
    Treprostinil: (Moderate) Monitor patients for signs and symptoms of bleeding if treprostinil is administered with abciximab. Treprostinil inhibits platelet aggregation; abciximab is a platelet inhibitor. Coadministration increases the risk of bleeding.
    Tretinoin, ATRA: (Moderate) An additive risk of bleeding may occur when platelet inhibitors are used with agents that cause clinically significant thrombocytopenia including antineoplastic agents, such as tretinoin.
    Venlafaxine: (Moderate) Monitor closely for signs and symptoms of bleeding during concurrent use of venlafaxine and abciximab. Platelet aggregation may be impaired by serotonin norepinephrine reuptake inhibitors (SNRIs) like venlafaxine due to platelet serotonin depletion, possibly increasing the risk of a bleeding complication in patients receiving abciximab.
    Verteporfin: (Minor) Agents, such as platelet inhibitors, that decrease clotting could decrease the efficacy of photosensitizing agents used in photodynamic therapy.
    Vilazodone: (Moderate) Patients should be instructed to monitor for signs and symptoms of bleeding while taking vilazodone concurrently with salicylates or other platelet inhibitors and to promptly report any bleeding events to the practitioner. Platelet aggregation may be impaired by vilazodone due to platelet serotonin depletion, possibly increasing the risk of a bleeding complication (e.g., gastrointestinal bleeding, ecchymoses, epistaxis, hematomas, petechiae, hemorrhage) in patients receiving platelet inhibitors (e.g., aspirin, cilostazol, clopidogrel, dipyridamole, ticlopidine, platelet glycoprotein IIb/IIIa inhibitors).
    Vorapaxar: (Moderate) Because vorapaxar inhibits platelet aggregation, a potential additive risk for bleeding exists if vorapaxar is given in combination with other agents that affect hemostasis such as platelet glycoprotein IIb/IIIa inhibitors including abciximab, eptifibatide, and tirofiban.
    Vorinostat: (Moderate) Carefully monitor patients for signs and symptoms of bleeding during coadministration of abciximab and vorinostat. Due to the thrombocytopenic effects of vorinostat, an additive risk of bleeding may occur in patients taking platelet inhibitors.
    Vortioxetine: (Moderate) Platelet aggregation may be impaired by vortioxetine due to platelet serotonin depletion, possibly increasing the risk of a bleeding complication (e.g., gastrointestinal bleeding, ecchymoses, epistaxis, hematomas, petechiae, hemorrhage) in patients receiving platelet inhibitors (e.g., cilostazol, clopidogrel, dipyridamole, ticlopidine, platelet glycoprotein IIb/IIIa inhibitors). Bleeding events related to drugs that inhibit serotonin reuptake have ranged from ecchymosis to life-threatening hemorrhages. Patients should be instructed to monitor for signs and symptoms of bleeding while taking vortioxetine concurrently with an antiplatelet medication and to promptly report any bleeding events to the practitioner.
    Warfarin: (Moderate) The use of abciximab within 7 days of use an oral anticoagulant is contraindicated unless the patient's prothrombin time is less than or equal to 1.2 times the control value. Because abciximab inhibits platelet aggregation, additive effects may be seen when abciximab is given in combination with other agents that affect hemostasis such as other platelet inhibitors (e.g. aspirin, ASA, clopidogrel, dipyridamole, ticlopidine), thrombolytic agents (e.g. alteplase, reteplase, streptokinase), and anticoagulants (e.g., heparin, warfarin). However, in clinical trials with abciximab, aspirin and heparin were administered concomitantly. The bleeding risk is significantly increased with concurrent abciximab and thrombolytic therapy; the risks of combination therapy should be weighed against the potential benefits. The GUSTO V study evaluated reduced-dose reteplase in combination with full dose abciximab, in comparison to full dose reteplase alone in patients with acute myocardial infarction (MI); all patients received concurrent aspirin and heparin therapy. The combination regimen was associated with a two-fold increase in moderate to severe non-intracranial bleeding complications, including spontaneous GI bleeding. In addition, large doses of salicylates (>= 3 to 4 g/day) can cause hypoprothrombinemia, an additional risk factor for bleeding. Although NSAIDs lacks platelet inhibitory effects, an increased risk for GI bleeding is possible when NSAIDs are administered during abciximab therapy.

    PREGNANCY AND LACTATION

    Pregnancy

    Animal reproduction studies have not been conducted with abciximab, and it is unknown if abciximab can cause fetal harm when administered during pregnancy or if it can affect reproduction capacity. Use abciximab during pregnancy only if clearly needed.[29816]

    It is unknown whether abciximab is excreted into breast milk or absorbed systemically after ingestion. Because many drugs are excreted in human milk, use caution when administering abciximab to a woman who is breast-feeding.[29816]

    MECHANISM OF ACTION

    Mechanism of Action: Abciximab is a noncompetitive inhibitor of glycoprotein (GP) IIb/IIIa preventing the binding of fibrinogen,von Willebrand factor (vWF), and other adhesive ligands to the GP IIb/IIIa receptor on activated platelets. "Integrins", which are found on virtually all cell types, are a family of adhesion molecules that mediate many physiologic responses. Unlike many of the other integrins, GP IIb/IIIa is platelet specific and is the most abundant receptor found on activated platelets, with about 50,000—80,000 copies/cell. Fibrinogen is the principal ligand to bind to the GP IIb/IIIa receptor. The binding of fibrinogen and other ligands, such as vWF, to the GP IIb/IIIa receptor results in cross-linking between platelets and is the final common pathway of platelet aggregation, which ultimately leads to thrombus formation. The mechanism of abciximab is believed to involve steric hindrance and/or conformational effects to block the access of fibrinogen and vWF to GP IIb/IIIa receptor sites. Blockade of the receptor sites subsequently prevents platelet aggregation. Maximal inhibition of platetet aggregation occurs when >= 80% of GP IIb/IIIa receptors are blocked by abciximab.Abciximab not only binds GP IIb/IIIa, but also other integrins such as the vitronectin receptor. The vitronectin receptor has a regulatory role in the processes of cell adhesion, migration, and proliferation; it is also upregulated under conditions of rapid vascular growth, such as angiogenesis. Inhibition of vitronectin-induced cell proliferation may have a role in the prevention of restenosis; however, the long-term benefits of vitronectin inhibition have not been proven. Abciximab can act as an anticoagulant. Abciximab anticoagulant activity may be due to potent GP IIb/IIIa activity or the vitronectin receptor may be involved.

    PHARMACOKINETICS

    Abciximab is administered by intravenous bolus injection followed by intravenous infusion. Data describing abciximab's metabolism are not available. The initial elimination half-life of free abciximab plasma concentrations is less than 10 minutes, with a second-phase half-life of about 30 minutes. Intravenous administration of a bolus dose of abciximab followed by continuous infusion according to recommended doses produces approximately constant free plasma concentrations throughout the infusion. At the termination of the infusion period, free plasma concentrations fall rapidly for approximately 6 hours then decline at a slower rate. Low levels of GP IIb/IIIa receptor blockade may be present for more than 10 days following discontinuation of the abciximab infusion. Platelet function generally recovers over the course of 48 hours despite the fact that abciximab remains in the circulation at low levels for more than 10 days.

    Intravenous Route

    Data are limited regarding the distribution of abciximab; however, the pharmacodynamic effects of the drug are well described. A bolus intravenous dose of abciximab is rapidly bound to platelet receptors and increases median bleeding time from about 5 minutes to over 30 minutes. Two hours after a bolus dose, over 80% of glycoprotein (GP) IIb/IIIa receptors are blocked and platelet aggregation is almost nonexistent. Blockade of >= 80% of GP IIb/IIIa receptors can be maintained by administration of a 0.125 mcg/kg/minute (maximum of 10 mcg/minute) continuous IV infusion. A lower continuous infusion dose was found insufficient to maintain the initial response. When an infusion of abciximab is stopped, there is an initial rapid decline in plasma concentrations over the first 6 hours, followed by a slower decline. Bleeding time usually declines to <= 12 minutes within 12 hours of discontinuation in about 75% of patients and within 24 hours in about 90% of patients. Ex vivo platelet aggregation in response to 20 mcM adenosine diphosphate returns to >= 50% of baseline within 24 hours in about 62% of patients and within 48 hours in roughly 88% of patients.