ARGATROBAN: 683 Adverse Event Reports & Safety Profile

Argatroban is a synthetic direct thrombin inhibitor and the chemical name is 1-[5-[(aminoiminomethyl)amino]-1-oxo-2-[[(1,2,3,4-tetrahydro-3-methyl-8- quinolinyl)sulfonyl]amino]pentyl]-4-methyl-2-piperidinecarboxylic acid, monohydrate. Argatroban has 4 asymmetric carbons. One of the asymmetric carbons has an R configuration (stereoisomer Type I) and an S configuration (stereoisomer Type II). Argatroban consists of a mixture of R and S stereoisomers at a ratio of approximately 65:35. The molecular formula of argatroban is C 23 H 36 N 6 O 5 S•H 2 O. Its molecular weight is 526.66 g/mol. The structural formula is shown below: Argatroban is a white, odorless crystalline powder that is freely soluble in glacial acetic acid, slightly soluble in ethanol, and insoluble in acetone, ethyl acetate, and ether.

Argatroban Injection

250 mg/2.5 mL (100 mg/mL) is a sterile clear, colorless to pale yellow, slightly viscous solution.

Argatroban Injection

250 mg/2.5 mL (100 mg/mL) is available in 250-mg (in 2.5-mL) single-dose amber vials, with white flip-top caps. Each mL of sterile, nonpyrogenic solution contains 100 mg Argatroban. Inert ingredients (per vial): 1300 mg Propylene glycol, 760 mg Dehydrated alcohol.

Argatroban Injection

50 mg/50 mL (1 mg/mL) is a sterile clear, colorless to pale yellow, solution.

Argatroban Injection

50 mg/50 mL (1 mg/mL) is available in 50-mg (in 50-mL) single-dose vials, with white flip-top caps. Each mL of sterile, nonpyrogenic solution contains 1 mg Argatroban. Inert ingredients (per vial): 260 mg Propylene glycol, 152 mg Dehydrated alcohol, and 450 mg Sodium Chloride. Arg chem structure

AND USAGE Argatroban is a direct thrombin inhibitor indicated:

• For prophylaxis or treatment of thrombosis in adult patients with heparin-induced thrombocytopenia (HIT) ( 1.1 ).
• As an anticoagulant in adult patients with or at risk for HIT undergoing percutaneous coronary intervention (PCI) ( 1.2 ).

1.1 Heparin-Induced Thrombocytopenia Argatroban injection is indicated for prophylaxis or treatment of thrombosis in adult patients with heparin-induced thrombocytopenia (HIT).

1.2 Percutaneous Coronary Intervention Argatroban injection is indicated as an anticoagulant in adult patients with or at risk for HIT undergoing percutaneous coronary intervention (PCI).

1.1 Heparin-Induced Thrombocytopenia Argatroban injection is indicated for prophylaxis or treatment of thrombosis in adult patients with heparin-induced thrombocytopenia (HIT).

1.2 Percutaneous Coronary Intervention Argatroban injection is indicated as an anticoagulant in adult patients with or at risk for HIT undergoing percutaneous coronary intervention (PCI).

AND ADMINISTRATION Argatroban injection must be diluted 100-fold by mixing with 0.9% Sodium Chloride Injection, 5% Dextrose Injection or Lactated Ringer’s Injection to a final concentration of 1 mg/mL prior to administration ( 2.1 ). Heparin-Induced Thrombocytopenia The dose for heparin-induced thrombocytopenia without hepatic impairment is 2 mcg/kg/min administered as a continuous infusion ( 2.1 ).

Percutaneous Coronary Intervention

The dose for patients with or at risk for heparin-induced thrombocytopenia undergoing percutaneous coronary intervention is started at 25 mcg/kg/min and a bolus of 350 mcg/kg administered via a large bore intravenous line over 3 to 5 minutes ( 2.2 ).

2.1 Preparation for Intravenous Administration Argatroban injection 250 mg per 2.5 mL (100 mg per mL) must be diluted 100-fold prior to infusion. Argatroban injection should not be mixed with other drugs prior to dilution. Prior to administration, argatroban injection should be diluted in 0.9% Sodium Chloride Injection, 5% Dextrose Injection, or Lactated Ringer’s Injection to a final concentration of 1 mg/mL. The contents of each 2.5 mL vial should be diluted 100-fold by mixing with 250 mL of diluent.

Use

250 mg (2.5 mL) per 250 mL of diluent or 500 mg (5 mL) per 500 mL of diluent. The constituted solution must be mixed by repeated inversion of the diluent bag for 1 minute. Upon preparation, the solution may show slight haziness due to the formation of microprecipitates that dissolve upon continued mixing. Ionic solutions such as 0.9% Sodium Chloride or Lactated Ringers may require a longer mixing time. Use of diluent at room temperature is recommended. The final solution must be clear before use. If the solution is cloudy, or if an insoluble precipitate is noted, the bag should be discarded. The pH of the intravenous solution prepared as recommended is 3.2 to 7.5. Solutions prepared are physically, chemically, and microbiologically stable when stored as directed below in Table 1 and protected from light: Table 1 Recommended Storage Conditions of Diluted Solution Diluent Storage Limit Storage Temperature 0.9% Sodium Chloride Injection 96 hours 20 to 25°C (68 to 77°F) 96 hours 2 to 8°C (36 to 46°F) 5% Dextrose Injection or Lactated Ringer’s Injection 4 hours 20 to 25°C (68 to 77°F) 4 hours 2 to 8°C (36 to 46°F) Discard unused final product at the completion of these post dilution storage periods. Prepared solutions should not be exposed to direct sunlight. No significant potency losses have been noted following simulated delivery of the solution through intravenous tubing. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit.

2.2 Dosing in Patients with Heparin-Induced Thrombocytopenia Initial Dosage: Before administering argatroban injection, discontinue heparin therapy and obtain a baseline aPTT. The recommended initial dose of argatroban injection for adult patients without hepatic impairment is 2 mcg/kg/min, administered as a continuous infusion (see Table 2 ).

Table

2 Recommended Doses and Infusion Rates for 2 mcg/kg/min Dose of Argatroban Injection for Patients with HIT* and Without Hepatic Impairment (1 mg/mL Final Concentration)

Body

Weight (kg) Dose (mcg/min)

Infusion

Rate (mL/hr) 50 100 6 60 120 7 70 140 8 80 160 10 90 180 11 100 200 12 110 220 13 120 240 14 130 260 16 140 280 17 *with or without thrombosis Monitoring Therapy: For use in HIT, therapy with argatroban injection is monitored using the aPTT with a target range of 1.5 to 3 times the initial baseline value (not to exceed 100 seconds). Tests of anticoagulant effects (including the aPTT) typically attain steady-state levels within 1 to 3 hours following initiation of argatroban injection. Check the aPTT 2 hours after initiation of therapy and after any dose change to confirm that the patient has attained the desired therapeutic range.

Dosage

Adjustment: After the initiation of argatroban injection, adjust the dose (not to exceed 10 mcg/kg/min) as necessary to obtain a steady-state aPTT in the target range [see Clinical Studies (14.1) ] .

2.3 Dosing in Patients Undergoing Percutaneous Coronary Intervention Initial Dosage: Initiate an infusion of argatroban injection at 25 mcg/kg/min and administer a bolus of 350 mcg/kg via a large bore intravenous line over 3 to 5 minutes (see Table 3 ). Check an activated clotting time (ACT) 5 to 10 minutes after the bolus dose is completed. The PCI procedure may proceed if the ACT is greater than 300 seconds.

Dosage

Adjustment: If the ACT is less than 300 seconds, an additional intravenous bolus dose of 150 mcg/kg should be administered, the infusion dose increased to 30 mcg/kg/min, and the ACT checked 5 to 10 minutes later (see Table 3 ). If the ACT is greater than 450 seconds, decrease the infusion rate to 15 mcg/kg/min, and check the ACT 5 to 10 minutes later (see Table 4 ). Continue titrating the dose until a therapeutic ACT (between 300 and 450 seconds) has been achieved; continue the same infusion rate for the duration of the PCI procedure. In case of dissection, impending abrupt closure, thrombus formation during the procedure, or inability to achieve or maintain an ACT over 300 seconds, additional bolus doses of 150 mcg/kg may be administered and the infusion dose increased to 40 mcg/kg/min. Check the ACT after each additional bolus or change in the rate of infusion.

Table

3 Recommended Starting and Maintenance Doses (Within the Target ACT Range) of Argatroban Injection in Patients Undergoing PCI Without Hepatic Impairment (1 mg/mL Final Concentration)

Body

Weight (kg)

Starting Bolus

Dose (350 mcg/kg) Starting and Maintenance Continuous Infusion Dosing For ACT 300 to 450 seconds 25 mcg/kg/min Bolus Dose (mcg)

Bolus

Volume (mL)

Continuous Infusion

Dose (mcg/min)

Continuous Infusion

Rate (mL/hr) 50 17,500 18 1,250 75 60 21,000 21 1,500 90 70 24,500 25 1,750 105 80 28,000 28 2,000 120 90 31,500 32 2,250 135 100 35,000 35 2,500 150 110 38,500 39 2,750 165 120 42,000 42 3,000 180 130 45,500 46 3,250 195 140 49,000 49 3,500 210 NOTE: 1 mg = 1,000 mcg; 1 kg = 2.2 lbs Table 4 Recommended Dose Adjustments of Argatroban Injection for Patients Outside of ACT Target Range Undergoing PCI Without Hepatic Impairment (1 mg/mL Final Concentration)

Body

Weight (kg) If ACT Less than 300 seconds Dosage Adjustment † 30 mcg/kg/min If ACT Greater than 450 seconds Dosage Adjustment* 15 mcg/kg/min Additional Bolus Dose (mcg)

Bolus

Volume (mL)

Continuous Infusion

Dose (mcg/min)

Continuous Infusion

Rate (mL/hr)

Continuous Infusion

Dose (mcg/min)

Continuous Infusion

Rate (mL/hr) 50 7,500 8 1,500 90 750 45 60 9,000 9 1,800 108 900 54 70 10,500 11 2,100 126 1,050 63 80 12,000 12 2,400 144 1,200 72 90 13,500 14 2,700 162 1,350 81 100 15,000 15 3,000 180 1,500 90 110 16,500 17 3,300 198 1,650 99 120 18,000 18 3,600 216 1,800 108 130 19,500 20 3,900 234 1,950 117 140 21,000 21 4,200 252 2,100 126 NOTE: 1 mg = 1,000 mcg; 1 kg = 2.2 lbs † Additional intravenous bolus dose of 150 mcg/kg should be administered if ACT less than 300 seconds. * No bolus dose is given if ACT greater than 450 seconds Monitoring Therapy: For use in PCI, therapy with argatroban injection is monitored using ACT. Obtain ACTs before dosing, 5 to 10 minutes after bolus dosing, following adjustments in the infusion rate, and at the end of the PCI procedure. Obtain additional ACTs every 20 to 30 minutes during a prolonged procedure.

Continued

Anticoagulation after PCI: If a patient requires anticoagulation after the procedure, argatroban injection may be continued, but at a rate of 2 mcg/kg/min and adjusted as needed to maintain the aPTT in the desired range [see Dosage and Administration (2.1) ] .

2.4 Dosing in Patients with Hepatic Impairment Initial Dosage: For adult patients with HIT and moderate or severe hepatic impairment (based on Child-Pugh classification), an initial dose of 0.5 mcg/kg/min is recommended, based on the approximately 4-fold decrease in argatroban injection clearance relative to those with normal hepatic function. Monitor the aPTT closely, and adjust the dosage as clinically indicated.

Monitoring

Therapy: Achievement of steady-state aPTT levels may take longer and require more dose adjustments in patients with hepatic impairment compared to patients with normal hepatic function. For patients with hepatic impairment undergoing PCI and who have HIT or are at risk for HIT, carefully titrate argatroban until the desired level of anticoagulation is achieved. Use of argatroban in PCI patients with clinically significant hepatic disease or AST/ALT levels greater than or equal to 3 times the upper limit of normal should be avoided [ see Warnings and Precautions (5.2) ] .

2.5 Conversion to Oral Anticoagulant Therapy Initiating Oral Anticoagulant Therapy: When converting patients from argatroban injection to oral anticoagulant therapy, consider the potential for combined effects on INR with co-administration of argatroban and warfarin. A loading dose of warfarin should not be used. Initiate therapy using the expected daily dose of warfarin. To avoid prothrombotic effects and to ensure continuous anticoagulation when initiating warfarin, it is suggested that argatroban and warfarin therapy be overlapped. There are insufficient data available to recommend the duration of the overlap. Co-Administration of Warfarin and Argatroban Injection at Doses up to 2 mcg/kg/min: Measure INR daily while argatroban injection and warfarin are co-administered. In general, with doses of argatroban injection up to 2 mcg/kg/min, argatroban injection can be discontinued when the INR is greater than 4 on combined therapy. After argatroban injection is discontinued, repeat the INR measurement in 4 to 6 hours. If the repeat INR is below the desired therapeutic range, resume the infusion of argatroban injection and repeat the procedure daily until the desired therapeutic range on warfarin alone is reached. Co-Administration of Warfarin and Argatroban Injection at Doses Greater than 2 mcg/kg/min: For doses of argatroban injection greater than 2 mcg/kg/min, the relationship of INR between warfarin alone to the INR on warfarin plus argatroban injection is less predictable. In this case, in order to predict the INR on warfarin alone, temporarily reduce the dose of argatroban injection to a dose of 2 mcg/kg/min. Repeat the INR on argatroban injection and warfarin 4 to 6 hours after reduction of the argatroban injection dose and follow the process outlined above for administering argatroban injection at doses up to 2 mcg/kg/min.

2.1 Preparation for Intravenous Administration Argatroban injection 250 mg per 2.5 mL (100 mg per mL) must be diluted 100-fold prior to infusion. Argatroban injection should not be mixed with other drugs prior to dilution. Prior to administration, argatroban injection should be diluted in 0.9% Sodium Chloride Injection, 5% Dextrose Injection, or Lactated Ringer’s Injection to a final concentration of 1 mg/mL. The contents of each 2.5 mL vial should be diluted 100-fold by mixing with 250 mL of diluent.

Use

250 mg (2.5 mL) per 250 mL of diluent or 500 mg (5 mL) per 500 mL of diluent. The constituted solution must be mixed by repeated inversion of the diluent bag for 1 minute. Upon preparation, the solution may show slight haziness due to the formation of microprecipitates that dissolve upon continued mixing. Ionic solutions such as 0.9% Sodium Chloride or Lactated Ringers may require a longer mixing time. Use of diluent at room temperature is recommended. The final solution must be clear before use. If the solution is cloudy, or if an insoluble precipitate is noted, the bag should be discarded. The pH of the intravenous solution prepared as recommended is 3.2 to 7.5. Solutions prepared are physically, chemically, and microbiologically stable when stored as directed below in Table 1 and protected from light: Table 1 Recommended Storage Conditions of Diluted Solution Diluent Storage Limit Storage Temperature 0.9% Sodium Chloride Injection 96 hours 20 to 25°C (68 to 77°F) 96 hours 2 to 8°C (36 to 46°F) 5% Dextrose Injection or Lactated Ringer’s Injection 4 hours 20 to 25°C (68 to 77°F) 4 hours 2 to 8°C (36 to 46°F) Discard unused final product at the completion of these post dilution storage periods. Prepared solutions should not be exposed to direct sunlight. No significant potency losses have been noted following simulated delivery of the solution through intravenous tubing. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit.

2.2 Dosing in Patients with Heparin-Induced Thrombocytopenia Initial Dosage: Before administering argatroban injection, discontinue heparin therapy and obtain a baseline aPTT. The recommended initial dose of argatroban injection for adult patients without hepatic impairment is 2 mcg/kg/min, administered as a continuous infusion (see Table 2 ).

Table

2 Recommended Doses and Infusion Rates for 2 mcg/kg/min Dose of Argatroban Injection for Patients with HIT* and Without Hepatic Impairment (1 mg/mL Final Concentration)

Body

Weight (kg) Dose (mcg/min)

Infusion

Rate (mL/hr) 50 100 6 60 120 7 70 140 8 80 160 10 90 180 11 100 200 12 110 220 13 120 240 14 130 260 16 140 280 17 *with or without thrombosis Monitoring Therapy: For use in HIT, therapy with argatroban injection is monitored using the aPTT with a target range of 1.5 to 3 times the initial baseline value (not to exceed 100 seconds). Tests of anticoagulant effects (including the aPTT) typically attain steady-state levels within 1 to 3 hours following initiation of argatroban injection. Check the aPTT 2 hours after initiation of therapy and after any dose change to confirm that the patient has attained the desired therapeutic range.

Dosage

Adjustment: After the initiation of argatroban injection, adjust the dose (not to exceed 10 mcg/kg/min) as necessary to obtain a steady-state aPTT in the target range [see Clinical Studies (14.1) ] .

2.3 Dosing in Patients Undergoing Percutaneous Coronary Intervention Initial Dosage: Initiate an infusion of argatroban injection at 25 mcg/kg/min and administer a bolus of 350 mcg/kg via a large bore intravenous line over 3 to 5 minutes (see Table 3 ). Check an activated clotting time (ACT) 5 to 10 minutes after the bolus dose is completed. The PCI procedure may proceed if the ACT is greater than 300 seconds.

Dosage

Adjustment: If the ACT is less than 300 seconds, an additional intravenous bolus dose of 150 mcg/kg should be administered, the infusion dose increased to 30 mcg/kg/min, and the ACT checked 5 to 10 minutes later (see Table 3 ). If the ACT is greater than 450 seconds, decrease the infusion rate to 15 mcg/kg/min, and check the ACT 5 to 10 minutes later (see Table 4 ). Continue titrating the dose until a therapeutic ACT (between 300 and 450 seconds) has been achieved; continue the same infusion rate for the duration of the PCI procedure. In case of dissection, impending abrupt closure, thrombus formation during the procedure, or inability to achieve or maintain an ACT over 300 seconds, additional bolus doses of 150 mcg/kg may be administered and the infusion dose increased to 40 mcg/kg/min. Check the ACT after each additional bolus or change in the rate of infusion.

Table

3 Recommended Starting and Maintenance Doses (Within the Target ACT Range) of Argatroban Injection in Patients Undergoing PCI Without Hepatic Impairment (1 mg/mL Final Concentration)

Body

Weight (kg)

Starting Bolus

Dose (350 mcg/kg) Starting and Maintenance Continuous Infusion Dosing For ACT 300 to 450 seconds 25 mcg/kg/min Bolus Dose (mcg)

Bolus

Volume (mL)

Continuous Infusion

Dose (mcg/min)

Continuous Infusion

Rate (mL/hr) 50 17,500 18 1,250 75 60 21,000 21 1,500 90 70 24,500 25 1,750 105 80 28,000 28 2,000 120 90 31,500 32 2,250 135 100 35,000 35 2,500 150 110 38,500 39 2,750 165 120 42,000 42 3,000 180 130 45,500 46 3,250 195 140 49,000 49 3,500 210 NOTE: 1 mg = 1,000 mcg; 1 kg = 2.2 lbs Table 4 Recommended Dose Adjustments of Argatroban Injection for Patients Outside of ACT Target Range Undergoing PCI Without Hepatic Impairment (1 mg/mL Final Concentration)

Body

Weight (kg) If ACT Less than 300 seconds Dosage Adjustment † 30 mcg/kg/min If ACT Greater than 450 seconds Dosage Adjustment* 15 mcg/kg/min Additional Bolus Dose (mcg)

Bolus

Volume (mL)

Continuous Infusion

Dose (mcg/min)

Continuous Infusion

Rate (mL/hr)

Continuous Infusion

Dose (mcg/min)

Continuous Infusion

Rate (mL/hr) 50 7,500 8 1,500 90 750 45 60 9,000 9 1,800 108 900 54 70 10,500 11 2,100 126 1,050 63 80 12,000 12 2,400 144 1,200 72 90 13,500 14 2,700 162 1,350 81 100 15,000 15 3,000 180 1,500 90 110 16,500 17 3,300 198 1,650 99 120 18,000 18 3,600 216 1,800 108 130 19,500 20 3,900 234 1,950 117 140 21,000 21 4,200 252 2,100 126 NOTE: 1 mg = 1,000 mcg; 1 kg = 2.2 lbs † Additional intravenous bolus dose of 150 mcg/kg should be administered if ACT less than 300 seconds. * No bolus dose is given if ACT greater than 450 seconds Monitoring Therapy: For use in PCI, therapy with argatroban injection is monitored using ACT. Obtain ACTs before dosing, 5 to 10 minutes after bolus dosing, following adjustments in the infusion rate, and at the end of the PCI procedure. Obtain additional ACTs every 20 to 30 minutes during a prolonged procedure.

Continued

Anticoagulation after PCI: If a patient requires anticoagulation after the procedure, argatroban injection may be continued, but at a rate of 2 mcg/kg/min and adjusted as needed to maintain the aPTT in the desired range [see Dosage and Administration (2.1) ] .

2.4 Dosing in Patients with Hepatic Impairment Initial Dosage: For adult patients with HIT and moderate or severe hepatic impairment (based on Child-Pugh classification), an initial dose of 0.5 mcg/kg/min is recommended, based on the approximately 4-fold decrease in argatroban injection clearance relative to those with normal hepatic function. Monitor the aPTT closely, and adjust the dosage as clinically indicated.

Monitoring

Therapy: Achievement of steady-state aPTT levels may take longer and require more dose adjustments in patients with hepatic impairment compared to patients with normal hepatic function. For patients with hepatic impairment undergoing PCI and who have HIT or are at risk for HIT, carefully titrate argatroban until the desired level of anticoagulation is achieved. Use of argatroban in PCI patients with clinically significant hepatic disease or AST/ALT levels greater than or equal to 3 times the upper limit of normal should be avoided [ see Warnings and Precautions (5.2) ] .

2.5 Conversion to Oral Anticoagulant Therapy Initiating Oral Anticoagulant Therapy: When converting patients from argatroban injection to oral anticoagulant therapy, consider the potential for combined effects on INR with co-administration of argatroban and warfarin. A loading dose of warfarin should not be used. Initiate therapy using the expected daily dose of warfarin. To avoid prothrombotic effects and to ensure continuous anticoagulation when initiating warfarin, it is suggested that argatroban and warfarin therapy be overlapped. There are insufficient data available to recommend the duration of the overlap. Co-Administration of Warfarin and Argatroban Injection at Doses up to 2 mcg/kg/min: Measure INR daily while argatroban injection and warfarin are co-administered. In general, with doses of argatroban injection up to 2 mcg/kg/min, argatroban injection can be discontinued when the INR is greater than 4 on combined therapy. After argatroban injection is discontinued, repeat the INR measurement in 4 to 6 hours. If the repeat INR is below the desired therapeutic range, resume the infusion of argatroban injection and repeat the procedure daily until the desired therapeutic range on warfarin alone is reached. Co-Administration of Warfarin and Argatroban Injection at Doses Greater than 2 mcg/kg/min: For doses of argatroban injection greater than 2 mcg/kg/min, the relationship of INR between warfarin alone to the INR on warfarin plus argatroban injection is less predictable. In this case, in order to predict the INR on warfarin alone, temporarily reduce the dose of argatroban injection to a dose of 2 mcg/kg/min. Repeat the INR on argatroban injection and warfarin 4 to 6 hours after reduction of the argatroban injection dose and follow the process outlined above for administering argatroban injection at doses up to 2 mcg/kg/min.

Argatroban in sodium chloride injection is contraindicated in: Patients with major bleeding, [ see Warnings and Precautions (5.1) ] Patients with a history of hypersensitivity to argatroban products. Airway, skin, and generalized hypersensitivity reactions have been reported [ see Adverse Reactions (6.1) ] . Major bleeding (4) History of hypersensitivity to this product (4)

REACTIONS The following adverse reaction is also discussed in other sections of the labeling:

• Risk of Hemorrhage [see Warnings and Precautions (5.1) ] .
• HIT patients: The most common (> 5%) adverse reactions were dyspnea, hypotension, fever, diarrhea, sepsis, and cardiac arrest ( 6.1 ).
• PCI patients: The most common (> 5%) adverse reactions were chest pain, hypotension, back pain, nausea, vomiting and headache ( 6.2 ). To report SUSPECTED ADVERSE REACTIONS, contact Fresenius Kabi USA, LLC at 1-800-551-7176 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

6.1 Adverse Events in Patients with HIT (with or without Thrombosis) Because clinical trials are conducted under widely varying conditions, adverse event rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The following safety information is based on all 568 patients treated with argatroban in Study 1 and Study 2. The safety profile of the patients from these studies is compared with that of 193 historical controls in which the adverse events were collected retrospectively. Adverse events are separated into hemorrhagic and non-hemorrhagic events. Major bleeding was defined as bleeding that was overt and associated with a hemoglobin decrease > 2 g/dL, that led to a transfusion of > 2 units, or that was intracranial, retroperitoneal, or into a major prosthetic joint. Minor bleeding was overt bleeding that did not meet the criteria for major bleeding.

Table

5 gives an overview of the most frequently observed hemorrhagic events, presented separately by major and minor bleeding, sorted by decreasing occurrence among argatroban-treated patients with HIT (with or without thrombosis).

Table

5 Major and Minor Hemorrhagic Adverse Events in Patients with HIT* Major Hemorrhagic Events a Argatroban-Treated Patients (Study 1 and Study 2) (n = 568) % Historical Control c (n = 193) % Overall bleeding 5.3

6.7 Gastrointestinal 2.3

1.6 Genitourinary and hematuria 0.9

0.5 Decrease in hemoglobin and hematocrit 0.7 0 Multisystem hemorrhage and DIC 0.5 1 Limb and BKA stump 0.5 0 Intracranial hemorrhage 0 b

0.5 Minor Hemorrhagic Events a Gastrointestinal 14.4

18.1 Genitourinary and hematuria 11.6

0.8 Decrease in hemoglobin and hematocrit 10.4 0 Groin 5.4

3.1 Hemoptysis 2.9

0.8 Brachial 2.4 0.8 * with or without thrombosis a Patients may have experienced more than 1 adverse event. b One patient experienced intracranial hemorrhage 4 days after discontinuation of argatroban and following therapy with urokinase and oral anticoagulation. c The historical control group consisted of patients with a clinical diagnosis of HIT (with or without thrombosis) that were considered eligible by an independent medical panel. DIC = disseminated intravascular coagulation. BKA = below-the-knee amputation.

Table

6 gives an overview of the most frequently observed non-hemorrhagic events sorted by decreasing frequency of occurrence (greater than or equal to 2%) among argatroban-treated HIT/HITTS patients.

Table

6 Non-hemorrhagic Adverse Events in Patients a with HIT b Argatroban-Treated Patients (Study 1 and Study 2) (n = 568) % Historical Control c (n = 193) % Dyspnea 8.1

8.8 Hypotension 7.2

2.6 Fever 6.9

2.1 Diarrhea 6.2

1.6 Sepsis 6

12.4 Cardiac arrest 5.8

3.1 Nausea 4.8

0.5 Ventricular tachycardia 4.8

3.1 Pain 4.6

3.1 Urinary tract infection 4.6

5.2 Vomiting 4.2 0 Infection 3.7

3.6 Pneumonia 3.3

9.3 Atrial fibrillation 3

11.4 Coughing 2.8

1.6 Abnormal renal function 2.8

4.7 Abdominal pain 2.6

1.6 Cerebrovascular disorder 2.3 4.1 a Patients may have experienced more than 1 adverse event. b with or without thrombosis c The historical control group consisted of patients with a clinical diagnosis of HIT (with or without thrombosis) that were considered eligible by an independent medical panel.

6.2 Adverse Events in Patients with or at Risk for HIT Patients Undergoing PCI The following safety information is based on 91 patients initially treated with argatroban and 21 patients subsequently re-exposed to argatroban for a total of 112 PCIs with argatroban anticoagulation. Adverse events are separated into hemorrhagic ( Table 7 ) and non-hemorrhagic ( Table 8 ) events. Major bleeding was defined as bleeding that was overt and associated with a hemoglobin decrease > 5 g/dL, that led to a transfusion of > 2 units, or that was intracranial, retroperitoneal, or into a major prosthetic joint. The rate of major bleeding events in patients treated with argatroban in the PCI trials was 1.8%.

Table

7 Major and Minor Hemorrhagic Adverse Events in Patients with HIT Undergoing PCI Major Hemorrhagic Events a Argatroban-Treated Patients (n = 112) b % Retroperitoneal

0.9 Gastrointestinal

0.9 Intracranial 0 Minor Hemorrhagic Events a Argatroban-Treated Patients (n = 112) b % Groin (bleeding or hematoma)

3.6 Gastrointestinal (includes hematemesis)

2.6 Genitourinary (includes hematuria)

1.8 Decrease in hemoglobin and/or hematocrit

1.8 CABG (coronary arteries)

1.8 Access site

0.9 Hemoptysis

0.9 Other 0.9 a Patients may have experienced more than 1 adverse event. b 91 patients who underwent 112 interventions. CABG = coronary artery bypass graft.

Table

8 gives an overview of the most frequently observed non-hemorrhagic events (greater than 2%), sorted by decreasing frequency of occurrence among argatroban-treated PCI patients.

Table

8 Non-hemorrhagic Adverse Events a in Patients with HIT Undergoing PCI Argatroban Procedures a (n = 112) b % Chest pain

15.2 Hypotension

10.7 Back pain 8 Nausea

7.1 Vomiting

6.3 Headache

5.4 Bradycardia

4.5 Abdominal pain

3.6 Fever

3.6 Myocardial infarction 3.6 a Patients may have experienced more than 1 adverse event. b 91 patients who underwent 112 interventions. There were 22 serious adverse events in 17 PCI patients (19.6% in 112 interventions).

Table

9 lists the serious adverse events occurring in argatroban-treated patients with or at risk for HIT undergoing PCI.

Table

9 Serious Adverse Events in Patients with HIT Undergoing PCI a Coded Term Argatroban Procedures b (n = 112) Myocardial infarction 4 (3.5%) Angina pectoris 2 (1.8%) Coronary thrombosis 2 (1.8%) Myocardial ischemia 2 (1.8%) Occlusion coronary 2 (1.8%) Chest pain 1 (0.9%)

Fever

1 (0.9%) Retroperitoneal hemorrhage 1 (0.9%) Aortic stenosis 1 (0.9%) Arterial thrombosis 1 (0.9%) Gastrointestinal hemorrhage 1 (0.9%) Gastrointestinal disorder (GERD) 1 (0.9%) Cerebrovascular disorder 1 (0.9%) Lung edema 1 (0.9%) Vascular disorder 1 (0.9%) a Individual events may also have been reported elsewhere (see Table 7 and 8 ). b 91 patients underwent 112 procedures. Some patients may have experienced more than 1 event.

6.3 Intracranial Bleeding in Other Populations Increased risks for intracranial bleeding have been observed in investigational studies of argatroban for other uses. In a study of patients with acute myocardial infarction receiving both argatroban and thrombolytic therapy (streptokinase or tissue plasminogen activator), the overall frequency of intracranial bleeding was 1% (8 out of 810 patients). Intracranial bleeding was not observed in 317 subjects or patients who did not receive concomitant thrombolysis <span class="opacity-50 text-xs">[see Drug Interactions (7.4) ]</span> . The safety and effectiveness of argatroban for cardiac indications other than PCI in patients with HIT have not been established. Intracranial bleeding was also observed in a prospective, placebo-controlled study of argatroban in patients who had onset of acute stroke within 12 hours of study entry. Symptomatic intracranial hemorrhage was reported in 5 of 117 patients (4.3%) who received argatroban at 1 to 3 mcg/kg/min and in none of the 54 patients who received placebo. Asymptomatic intracranial hemorrhage occurred in 5 (4.3%) and 2 (3.7%) of the patients, respectively.

6.4 Allergic Reactions One hundred fifty-six allergic reactions or suspected allergic reactions were observed in 1,127 individuals who were treated with argatroban in clinical pharmacology studies or for various clinical indications.

About

95% (148/156) of these reactions occurred in patients who concomitantly received thrombolytic therapy (e.g., streptokinase) or contrast media. Allergic reactions or suspected allergic reactions in populations other than patients with HIT (with or without thrombosis) include (in descending order of frequency):

• Airway reactions (coughing, dyspnea): 10% or more
• Skin reactions (rash, bullous eruption): 1 to less than 10%
• General reactions (vasodilation): 1 to 10% Limited data are available on the potential formation of drug-related antibodies. Plasma from 12 healthy volunteers treated with argatroban over 6 days showed no evidence of neutralizing antibodies. No loss of anticoagulant activity was noted with repeated administration of argatroban to more than 40 patients.

6.1 Adverse Events in Patients with HIT (with or without Thrombosis) Because clinical trials are conducted under widely varying conditions, adverse event rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The following safety information is based on all 568 patients treated with argatroban in Study 1 and Study 2. The safety profile of the patients from these studies is compared with that of 193 historical controls in which the adverse events were collected retrospectively. Adverse events are separated into hemorrhagic and non-hemorrhagic events. Major bleeding was defined as bleeding that was overt and associated with a hemoglobin decrease &gt; 2 g/dL, that led to a transfusion of &gt; 2 units, or that was intracranial, retroperitoneal, or into a major prosthetic joint. Minor bleeding was overt bleeding that did not meet the criteria for major bleeding.

Table

5 gives an overview of the most frequently observed hemorrhagic events, presented separately by major and minor bleeding, sorted by decreasing occurrence among argatroban-treated patients with HIT (with or without thrombosis).

Table

5 Major and Minor Hemorrhagic Adverse Events in Patients with HIT* Major Hemorrhagic Events a Argatroban-Treated Patients (Study 1 and Study 2) (n = 568) % Historical Control c (n = 193) % Overall bleeding 5.3

6.7 Gastrointestinal 2.3

1.6 Genitourinary and hematuria 0.9

0.5 Decrease in hemoglobin and hematocrit 0.7 0 Multisystem hemorrhage and DIC 0.5 1 Limb and BKA stump 0.5 0 Intracranial hemorrhage 0 b

0.5 Minor Hemorrhagic Events a Gastrointestinal 14.4

18.1 Genitourinary and hematuria 11.6

0.8 Decrease in hemoglobin and hematocrit 10.4 0 Groin 5.4

3.1 Hemoptysis 2.9

0.8 Brachial 2.4 0.8 * with or without thrombosis a Patients may have experienced more than 1 adverse event. b One patient experienced intracranial hemorrhage 4 days after discontinuation of argatroban and following therapy with urokinase and oral anticoagulation. c The historical control group consisted of patients with a clinical diagnosis of HIT (with or without thrombosis) that were considered eligible by an independent medical panel. DIC = disseminated intravascular coagulation. BKA = below-the-knee amputation.

Table

6 gives an overview of the most frequently observed non-hemorrhagic events sorted by decreasing frequency of occurrence (greater than or equal to 2%) among argatroban-treated HIT/HITTS patients.

Table

6 Non-hemorrhagic Adverse Events in Patients a with HIT b Argatroban-Treated Patients (Study 1 and Study 2) (n = 568) % Historical Control c (n = 193) % Dyspnea 8.1

8.8 Hypotension 7.2

2.6 Fever 6.9

2.1 Diarrhea 6.2

1.6 Sepsis 6

12.4 Cardiac arrest 5.8

3.1 Nausea 4.8

0.5 Ventricular tachycardia 4.8

3.1 Pain 4.6

3.1 Urinary tract infection 4.6

5.2 Vomiting 4.2 0 Infection 3.7

3.6 Pneumonia 3.3

9.3 Atrial fibrillation 3

11.4 Coughing 2.8

1.6 Abnormal renal function 2.8

4.7 Abdominal pain 2.6

1.6 Cerebrovascular disorder 2.3 4.1 a Patients may have experienced more than 1 adverse event. b with or without thrombosis c The historical control group consisted of patients with a clinical diagnosis of HIT (with or without thrombosis) that were considered eligible by an independent medical panel.

6.2 Adverse Events in Patients with or at Risk for HIT Patients Undergoing PCI The following safety information is based on 91 patients initially treated with argatroban and 21 patients subsequently re-exposed to argatroban for a total of 112 PCIs with argatroban anticoagulation. Adverse events are separated into hemorrhagic ( Table 7 ) and non-hemorrhagic ( Table 8 ) events. Major bleeding was defined as bleeding that was overt and associated with a hemoglobin decrease &gt; 5 g/dL, that led to a transfusion of &gt; 2 units, or that was intracranial, retroperitoneal, or into a major prosthetic joint. The rate of major bleeding events in patients treated with argatroban in the PCI trials was 1.8%.

Table

7 Major and Minor Hemorrhagic Adverse Events in Patients with HIT Undergoing PCI Major Hemorrhagic Events a Argatroban-Treated Patients (n = 112) b % Retroperitoneal

0.9 Gastrointestinal

0.9 Intracranial 0 Minor Hemorrhagic Events a Argatroban-Treated Patients (n = 112) b % Groin (bleeding or hematoma)

3.6 Gastrointestinal (includes hematemesis)

2.6 Genitourinary (includes hematuria)

1.8 Decrease in hemoglobin and/or hematocrit

1.8 CABG (coronary arteries)

1.8 Access site

0.9 Hemoptysis

0.9 Other 0.9 a Patients may have experienced more than 1 adverse event. b 91 patients who underwent 112 interventions. CABG = coronary artery bypass graft.

Table

8 gives an overview of the most frequently observed non-hemorrhagic events (greater than 2%), sorted by decreasing frequency of occurrence among argatroban-treated PCI patients.

Table

8 Non-hemorrhagic Adverse Events a in Patients with HIT Undergoing PCI Argatroban Procedures a (n = 112) b % Chest pain

15.2 Hypotension

10.7 Back pain 8 Nausea

7.1 Vomiting

6.3 Headache

5.4 Bradycardia

4.5 Abdominal pain

3.6 Fever

3.6 Myocardial infarction 3.6 a Patients may have experienced more than 1 adverse event. b 91 patients who underwent 112 interventions. There were 22 serious adverse events in 17 PCI patients (19.6% in 112 interventions).

Table

9 lists the serious adverse events occurring in argatroban-treated patients with or at risk for HIT undergoing PCI.

Table

9 Serious Adverse Events in Patients with HIT Undergoing PCI a Coded Term Argatroban Procedures b (n = 112) Myocardial infarction 4 (3.5%) Angina pectoris 2 (1.8%) Coronary thrombosis 2 (1.8%) Myocardial ischemia 2 (1.8%) Occlusion coronary 2 (1.8%) Chest pain 1 (0.9%)

Fever

1 (0.9%) Retroperitoneal hemorrhage 1 (0.9%) Aortic stenosis 1 (0.9%) Arterial thrombosis 1 (0.9%) Gastrointestinal hemorrhage 1 (0.9%) Gastrointestinal disorder (GERD) 1 (0.9%) Cerebrovascular disorder 1 (0.9%) Lung edema 1 (0.9%) Vascular disorder 1 (0.9%) a Individual events may also have been reported elsewhere (see Table 7 and 8 ). b 91 patients underwent 112 procedures. Some patients may have experienced more than 1 event.

6.3 Intracranial Bleeding in Other Populations Increased risks for intracranial bleeding have been observed in investigational studies of argatroban for other uses. In a study of patients with acute myocardial infarction receiving both argatroban and thrombolytic therapy (streptokinase or tissue plasminogen activator), the overall frequency of intracranial bleeding was 1% (8 out of 810 patients). Intracranial bleeding was not observed in 317 subjects or patients who did not receive concomitant thrombolysis <span class="opacity-50 text-xs">[see Drug Interactions (7.4) ]</span> . The safety and effectiveness of argatroban for cardiac indications other than PCI in patients with HIT have not been established. Intracranial bleeding was also observed in a prospective, placebo-controlled study of argatroban in patients who had onset of acute stroke within 12 hours of study entry. Symptomatic intracranial hemorrhage was reported in 5 of 117 patients (4.3%) who received argatroban at 1 to 3 mcg/kg/min and in none of the 54 patients who received placebo. Asymptomatic intracranial hemorrhage occurred in 5 (4.3%) and 2 (3.7%) of the patients, respectively.

6.4 Allergic Reactions One hundred fifty-six allergic reactions or suspected allergic reactions were observed in 1,127 individuals who were treated with argatroban in clinical pharmacology studies or for various clinical indications.

About

95% (148/156) of these reactions occurred in patients who concomitantly received thrombolytic therapy (e.g., streptokinase) or contrast media. Allergic reactions or suspected allergic reactions in populations other than patients with HIT (with or without thrombosis) include (in descending order of frequency):

• Airway reactions (coughing, dyspnea): 10% or more
• Skin reactions (rash, bullous eruption): 1 to less than 10%
• General reactions (vasodilation): 1 to 10% Limited data are available on the potential formation of drug-related antibodies. Plasma from 12 healthy volunteers treated with argatroban over 6 days showed no evidence of neutralizing antibodies. No loss of anticoagulant activity was noted with repeated administration of argatroban to more than 40 patients.

AND PRECAUTIONS

• Risk of hemorrhage: Hemorrhage at any site can occur (unexplained fall in hematocrit or blood pressure or other unexplained symptom may indicate hemorrhage.) Use with caution in patients at risk, including those receiving antiplatelet agents, thrombolytics, or other anticoagulants. ( 5.1 ).
• Use in hepatic impairment: Adjust starting dose and titrate carefully in patients with HIT who have moderate or severe hepatic impairment. Avoid use in PCI in patients with clinically significant hepatic impairment ( 5.2 ).

5.1 Risk of Hemorrhage Hemorrhage can occur at any site in the body in patients receiving argatroban. Unexplained fall in hematocrit or blood pressure may indicate hemorrhage. Intracranial and retroperitoneal hemorrhage have been reported <span class="opacity-50 text-xs">[see Adverse Reactions (6.1, 6.2 , and 6.3 )]</span> . The risk of hemorrhage with argatroban may be increased in severe hypertension, immediately following lumbar puncture, spinal anesthesia, major surgery (especially involving the brain, spinal cord, or eye), hematologic conditions associated with increased bleeding tendencies such as congenital or acquired bleeding disorders, and gastrointestinal lesions such as ulcerations. Concomitant use of argatroban with antiplatelet agents, thrombolytics, and other anticoagulants may increase the risk of bleeding.

5.2 Use in Hepatic Impairment When administering argatroban to patients with hepatic impairment, start with a lower dose and carefully titrate until the desired level of anticoagulation is achieved. Achievement of steady-state aPTT levels may take longer and require more argatroban dose adjustments in patients with hepatic impairment compared to patients with normal hepatic function <span class="opacity-50 text-xs">[see Use in Specific Populations (8.6) ]</span> . Also, upon cessation of argatroban infusion in the hepatically impaired patient, full reversal of anticoagulant effects may require longer than 4 hours due to decreased clearance and increased elimination half-life of argatroban <span class="opacity-50 text-xs">[see Dosage and Administration (2.3) and Clinical Pharmacology (12.3) ]</span> . Avoid the use of high doses of argatroban in patients undergoing PCI who have clinically significant hepatic disease or AST/ALT levels greater than or equal to 3 times the upper limit of normal.

5.3 Laboratory Tests Anticoagulation effects associated with argatroban infusion at doses up to 40 mcg/kg/min correlate with increases of the activated partial thromboplastin time (aPTT). Although other global clot-based tests including prothrombin time (PT), the International Normalized Ratio (INR), and thrombin time (TT) are affected by argatroban, the therapeutic ranges for these tests have not been identified for argatroban therapy. In clinical trials in PCI, the activated clotting time (ACT) was used for monitoring argatroban anticoagulant activity during the procedure. The concomitant use of argatroban and warfarin results in prolongation of the PT and INR beyond that produced by warfarin alone <span class="opacity-50 text-xs">[see Dosage and Administration ( 2.5 ) and Clinical Pharmacology ( 12.2 )]</span> .

5.1 Risk of Hemorrhage Hemorrhage can occur at any site in the body in patients receiving argatroban. Unexplained fall in hematocrit or blood pressure may indicate hemorrhage. Intracranial and retroperitoneal hemorrhage have been reported <span class="opacity-50 text-xs">[see Adverse Reactions (6.1, 6.2 , and 6.3 )]</span> . The risk of hemorrhage with argatroban may be increased in severe hypertension, immediately following lumbar puncture, spinal anesthesia, major surgery (especially involving the brain, spinal cord, or eye), hematologic conditions associated with increased bleeding tendencies such as congenital or acquired bleeding disorders, and gastrointestinal lesions such as ulcerations. Concomitant use of argatroban with antiplatelet agents, thrombolytics, and other anticoagulants may increase the risk of bleeding.

5.2 Use in Hepatic Impairment When administering argatroban to patients with hepatic impairment, start with a lower dose and carefully titrate until the desired level of anticoagulation is achieved. Achievement of steady-state aPTT levels may take longer and require more argatroban dose adjustments in patients with hepatic impairment compared to patients with normal hepatic function <span class="opacity-50 text-xs">[see Use in Specific Populations (8.6) ]</span> . Also, upon cessation of argatroban infusion in the hepatically impaired patient, full reversal of anticoagulant effects may require longer than 4 hours due to decreased clearance and increased elimination half-life of argatroban <span class="opacity-50 text-xs">[see Dosage and Administration (2.3) and Clinical Pharmacology (12.3) ]</span> . Avoid the use of high doses of argatroban in patients undergoing PCI who have clinically significant hepatic disease or AST/ALT levels greater than or equal to 3 times the upper limit of normal.

5.3 Laboratory Tests Anticoagulation effects associated with argatroban infusion at doses up to 40 mcg/kg/min correlate with increases of the activated partial thromboplastin time (aPTT). Although other global clot-based tests including prothrombin time (PT), the International Normalized Ratio (INR), and thrombin time (TT) are affected by argatroban, the therapeutic ranges for these tests have not been identified for argatroban therapy. In clinical trials in PCI, the activated clotting time (ACT) was used for monitoring argatroban anticoagulant activity during the procedure. The concomitant use of argatroban and warfarin results in prolongation of the PT and INR beyond that produced by warfarin alone <span class="opacity-50 text-xs">[see Dosage and Administration ( 2.5 ) and Clinical Pharmacology ( 12.2 )]</span> .

INTERACTIONS

• Heparin: Allow sufficient time for heparin’s effect on aPTT to decrease before initiating argatroban injection therapy ( 7.1 ).
• Warfarin: Concomitant use results in increased prolongation of PT and INR ( 7.2 ).
• Thrombolytic agents or glycoprotein IIb/IIIa antagonists: Safety and effectiveness of concomitant use with argatroban have not been established ( 7.4 , 7.5 ).

7.1 Heparin If argatroban is to be initiated after cessation of heparin therapy, allow sufficient time for heparin’s effect on the aPTT to decrease prior to initiation of argatroban therapy.

7.2 Oral Anticoagulant Agents Pharmacokinetic drug-drug interactions between argatroban and warfarin (7.5 mg single oral dose) have not been demonstrated. However, the concomitant use of argatroban and warfarin (5 to 7.5 mg initial oral dose, followed by 2.5 to 6 mg/day orally for 6 to 10 days) results in prolongation of the prothrombin time (PT) and International Normalized Ratio (INR) <span class="opacity-50 text-xs">[see Dosage and Administration ( 2.5 ) and Clinical Pharmacology ( 12.2 )]</span> .

7.3 Aspirin/Acetaminophen No drug-drug interactions have been demonstrated between argatroban and concomitantly administered aspirin or acetaminophen <span class="opacity-50 text-xs">[see Clinical Pharmacology (12.3) ]</span> .

7.4 Thrombolytic Agents The safety and effectiveness of argatroban with thrombolytic agents have not been established <span class="opacity-50 text-xs">[see Adverse Reactions (6.3) ]</span>.

7.5 Glycoprotein IIb/IIIa Antagonists The safety and effectiveness of argatroban with glycoprotein IIb/IIIa antagonists have not been established.

7.1 Heparin If argatroban is to be initiated after cessation of heparin therapy, allow sufficient time for heparin’s effect on the aPTT to decrease prior to initiation of argatroban therapy.

7.2 Oral Anticoagulant Agents Pharmacokinetic drug-drug interactions between argatroban and warfarin (7.5 mg single oral dose) have not been demonstrated. However, the concomitant use of argatroban and warfarin (5 to 7.5 mg initial oral dose, followed by 2.5 to 6 mg/day orally for 6 to 10 days) results in prolongation of the prothrombin time (PT) and International Normalized Ratio (INR) <span class="opacity-50 text-xs">[see Dosage and Administration ( 2.5 ) and Clinical Pharmacology ( 12.2 )]</span> .

7.3 Aspirin/Acetaminophen No drug-drug interactions have been demonstrated between argatroban and concomitantly administered aspirin or acetaminophen <span class="opacity-50 text-xs">[see Clinical Pharmacology (12.3) ]</span> .

7.4 Thrombolytic Agents The safety and effectiveness of argatroban with thrombolytic agents have not been established <span class="opacity-50 text-xs">[see Adverse Reactions (6.3) ]</span>.

7.5 Glycoprotein IIb/IIIa Antagonists The safety and effectiveness of argatroban with glycoprotein IIb/IIIa antagonists have not been established.