If streptokinase (SK) or anistreplase (APSAC) is used, heparin should be given only in those patients who are at high risk for systemic emboli (. large anterior MI, atrial fibrillation, previous embolus, or known LV thrombus) (See standard dosage). Heparin should not be given <= 4 hours after fibrinolytic therapy and should be given when the aPTT is < 70 (goal aPTT 50—70 seconds). After 48 hours, consideration may be given to subcutaneous heparin administration (initial dose about 17,500 Units every 12 hours to maintain aPTT —2 times control), LMWH, or oral anticoagulants. If the patient has no risk factors and SK or APSAC is the thrombolytic that was used, therapeutic heparin is not recommended.
Anticoagulants: Patients on anticoagulants such as warfarin should be carefully monitored during anabolic steroid therapy as anabolic steroids may increase sensitivity to oral anticoagulants which may require a concomitant reduction in anticoagulant dosage to achieve a desirable prothrombin time (PT). Anticoagulant patients should be monitored regularly during anabolic steroid therapy, particularly during initiation and termination of therapy. Warfarin patients should have INR and PT monitored throughout androgen therapy and warfarin dosages titrated to achieve the desired INR and PT. Such patients should be monitored for occult bleeding.
Bivalirudin is classified as FDA pregnancy risk category B. However, bivalirudin is intended for use with aspirin when administered for FDA-approved use in patients undergoing percutaneous coronary intervention (PCI). Aspirin is classified as pregnancy category C during the first and second trimesters and as pregnancy category D during the third trimester. Regular use of full-dose aspirin late in pregnancy may result in constriction or premature closure of the fetal ductus arteriosus. Animal data suggest bivalirudin causes no teratogenic effects when administered in the early stages of pregnancy or during the period of organogenesis. It is not known if the bivalirudin crosses the placental barrier in humans. There are no adequate and well-controlled studies in pregnant women. Bivalirudin with aspirin should only be used during pregnancy if clearly needed. Furthermore, bivalirudin should be used with extreme caution near term and during labor and obstetric delivery because of the possibility of maternal postpartum hemorrhage.