Consumer medicine information

Tirofiban Juno

Tirofiban

BRAND INFORMATION

Brand name

Tirofiban Juno

Active ingredient

Tirofiban

Schedule

What is in this leaflet

This leaflet answers some common questions about TIROFIBAN JUNO. It does not contain all the available information.

It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you using TIROFIBAN JUNO against the benefits they expect it will have for you.

If you have any concerns about being given this medicine, ask your doctor or pharmacist.

Keep this leaflet. You may need to read it again.

What TIROFIBAN JUNO is used for

TIROFIBAN JUNO, in combination with heparin (another medicine used to prevent blood clots), is used to prevent complications that may occur in people who have unstable angina (a type of chest pain) or are having a heart attack.

TIROFIBAN JUNO belongs to a group of medicines called platelet aggregation inhibitors.

It works by preventing cells in the blood, called platelets, from sticking together to form blood clots. If blood clots are not treated or prevented, they can block blood vessels. This can lead to complications such as angina or heart attacks.

Before you are given TIROFIBAN JUNO

When you must not be given it

Do not use TIROFIBAN JUNO if you have an allergy to TIROFIBAN JUNO or any of the ingredients listed at the end of this leaflet.

Do not use TIROFIBAN JUNO if you have any of the following medical conditions:

bleeding inside your body, or a history of increased tendency to bleeding, especially within the last 30 days
a history of bleeding in the brain or brain tumour
a history of abnormal or deformed arteries or veins
a history of swelling and weakening of a part of a blood vessel, also called aneursym
a history of stroke, especially within the last 30 days, or any history of stroke due to bleeding in the brain
major surgery or physical trauma, including falls or blows to the body or head, especially within the last month
a history, symptoms or signs of aortic dissection, a disease of a large blood vessel
severe, uncontrolled high blood pressure
pericarditis, a condition which involves swelling of the lining that surrounds the heart.

If you are not sure whether you should start receiving TIROFIBAN JUNO, talk to your doctor.

Do not use TIROFIBAN JUNO if you have received TIROFIBAN JUNO before and developed a low platelet count. If you are not sure whether you have received TIROFIBAN JUNO before and developed a low platelet count, ask your doctor.

Do not use TIROFIBAN JUNO if you are already receiving an injection of another 'platelet aggregation inhibitor' medicine.

Do not use TIROFIBAN JUNO if you are breast-feeding or intend to breast-feed. TIROFIBAN JUNO is not recommended for use while breast-feeding. It is not known whether it passes into breast milk.

Do not use TIROFIBAN JUNO in children. The safety and effectiveness in children have not been established.

Before you are given it

Tell your doctor if:

you are pregnant

Like most medicines, TIROFIBAN JUNO is generally not recommended during pregnancy.
However, if there is a need to consider using TIROFIBAN JUNO during pregnancy, your doctor will discuss the possible risks and benefits to you and your unborn baby.

you have or have had any medical conditions, especially the following:

any bleeding problems, including stomach bleeding, or blood in your urine or stools, within the last year
blood clotting problems or platelet diseases, including low platelet count
disease of the blood vessels of the brain, including stroke, within the last year
problems with the blood vessels in the back of your eye/s
kidney disease, or are undergoing dialysis

you have received platelet aggregation inhibitors before
you recently had an epidural (spinal) procedure
you have any allergies to any other medicines or any other substances, such as foods, preservatives or dyes.

If you have not told your doctor about any of the above, tell them before you are given TIROFIBAN JUNO.

Taking other medicines

Tell your doctor if you are taking any other medicines, including medicines that you buy without a prescription from your pharmacy, supermarket or health food shop. Some medicines and TIROFIBAN JUNO may interfere with each other. This includes:

medicines used to dissolve or prevent blood clots, including warfarin

These medicines may be affected by TIROFIBAN JUNO, or may affect how well it works. You may need different amounts of your medicine, or you may need to take different medicines.

Your doctor or pharmacist has more information on medicines to be careful with or to avoid while being given TIROFIBAN JUNO.

How TIROFIBAN JUNO is given

TIROFIBAN JUNO is given as a slow injection into a vein.

TIROFIBAN JUNO must only be given by a doctor or nurse.

Your doctor will decide what dose and how long you will receive TIROFIBAN JUNO. This depends on your condition and other factors, such as your weight and kidney function.

Side Effects

Tell your doctor, nurse, or pharmacist as soon as possible if you do not feel well while you are being given TIROFIBAN JUNO.

TIROFIBAN JUNO helps most people, but it may have unwanted side-effects in a few people. All medicines can have side effects.

Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

Ask your doctor or pharmacist to answer any questions you may have.

Tell your doctor or nurse immediately if you notice any unusual bleeding or bruising. This includes bleeding gums, nose bleeds, blood in your urine, bloody or black, tarry stools, coughing up blood, vomiting blood or material that looks like coffee grounds.

These may be serious side effects of TIROFIBAN JUNO. You may need urgent medical attention.

Also, tell your doctor or nurse immediately if you notice any of the following:

rash
pinkish, itchy swellings on the skin, also called hives or nettlerash
swelling of the face, lips, mouth or throat which may cause difficulty in swallowing or breathing
chills, dizziness, or wheezing

If you have them, you may be having an allergic reaction to TIROFIBAN JUNO. You may need urgent medical attention.

Tell your doctor or nurse if you notice any of the following and they worry you:

fever
nausea
headache

These are usually mild side effects of TIROFIBAN JUNO.

Other side effects not listed above may also occur in some patients.

Tell your doctor if you notice any other effects.

Do not be alarmed by this list of possible side effects. You may not experience any of them.

Storage

TIROFIBAN JUNO will be stored in the pharmacy or on the ward.

It is kept in a cool, dry place where it is protected from light and where the temperature stays below 25°C.

Product Description

What it looks like

TIROFIBAN JUNO comes in a glass vial, containing 50 mL of solution.

Ingredients

Active ingredient:

0.25 mg of tirofiban per mL

Inactive ingredients:

dibasic sodium phosphate dihydrate
mannitol
water for injections.
The pH may have been adjusted with hydrochloric acid and/or sodium hydroxide.

Supplier

TIROFIBAN JUNO is supplied in Australia by:

Juno Pharmaceuticals Pty Ltd
42 Kelso Street
Cremorne
Victoria 3121
Australia

This leaflet was prepared in August 2020.

Australian Register Number: AUST R 209216

Published by MIMS November 2020

BRAND INFORMATION

Brand name

Tirofiban Juno

Active ingredient

Tirofiban

Schedule

1 Name of Medicine

Tirofiban hydrochloride.

2 Qualitative and Quantitative Composition

Tirofiban Juno Concentrate for Infusion is a sterile concentrated solution for intravenous infusion after dilution and is supplied in a 50 mL glass vial. Each 50 mL vial contains 14.05 mg of tirofiban hydrochloride monohydrate equivalent to 12.5 mg of tirofiban and the following inactive ingredients: 78.0 mg dibasic sodium phosphate dihydrate, 2.25 g mannitol and water for injections. The pH ranges from 5.5 to 6.5 and may have been adjusted with hydrochloric acid and/or sodium hydroxide.

3 Pharmaceutical Form

Tirofiban Juno Concentrate for Infusion is a clear, colourless sterile solution, practically free from visible particles, in glass vials.

4 Clinical Particulars

4.1 Therapeutic Indications

Tirofiban Juno, in combination with heparin, is indicated for patients with unstable angina or non-Q wave myocardial infarction to prevent cardiac ischaemic events. (See Section 5.1 Pharmacodynamic Properties; Section 4.2 Dose and Method of Administration.)

4.2 Dose and Method of Administration

The vial of Tirofiban Juno (concentrate) must be diluted prior to administration (see Instructions for use).
Tirofiban Juno is for intravenous use only using sterile equipment. Tirofiban Juno may be co-administered with heparin through the same line. Tirofiban Juno should not be administered in the same intravenous line as diazepam.
Tirofiban Juno is recommended for use with a calibrated infusion device. Care should be taken to avoid a prolonged loading infusion. Care should also be taken in calculating the bolus dose and infusion rates based on patient weight.
In clinical studies patients received aspirin, unless contraindicated.
Tirofiban Juno should be administered intravenously at the initial infusion rate of 0.4 microgram/kg/min for 30 minutes. Upon completion of the initial infusion, Tirofiban Juno should be continued at a maintenance infusion rate of 0.1 microgram/kg/min. Tirofiban Juno should be given with heparin (usually an intravenous bolus dose of 5000 U simultaneously with the start of therapy with Tirofiban Juno, then approximately 1000 U per hour titrated on the basis of APTT, which should be about twice the normal value).
In the study that demonstrated efficacy, Tirofiban Juno in combination with heparin was generally continued for a minimum of 48 hours and up to 108 hours. This infusion can be continued through angiography and should be continued up to 12 to 24 hours post-angioplasty/atherectomy. Arterial sheaths should be removed when the patient's activated clotting time is < 180 seconds or 2-6 hours following cessation of heparin. (See Section 5.1 Pharmacodynamic Properties, Clinical trials.)

Patients with severe renal insufficiency.

The dosage of Tirofiban Juno should be decreased by 50% in patients with severe renal insufficiency (creatinine clearance < 30 mL/min). (See Section 4.4 Special Warnings and Precautions for Use, Severe renal insufficiency; Section 5.2 Pharmacokinetic Properties, Characteristics in patients, Renal insufficiency.)
Table 1 is provided as a guide to dosage adjustment by weight.

Other patient populations.

No dosage adjustment is recommended for elderly patients (see Section 4.4 Special Warnings and Precautions for Use, Use in the elderly) or female patients.

Instructions for use.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to use, whenever solution and container permit.

Concentrate for infusion.

The vial of Tirofiban Juno (concentrate) must be diluted prior to administration. It contains no antimicrobial agent. Use once only and discard any residue. For single use in one patient on one occasion only. Discard any remaining residue.

Directions for preparation of Tirofiban Juno solution for infusion from concentrate.

1. Withdraw and discard 50 mL from a 250 mL bag of sterile 0.9% sodium chloride injection or 5% glucose injection and replace it with 50 mL of Tirofiban Juno (from one 50 mL vial) to achieve a final concentration of 0.05 mg/mL. Mix well before administration.
Alternatively, withdraw and discard 100 mL from a 500 mL bag of sterile 0.9% sodium chloride injection or 5% glucose injection and replace it with 100 mL of Tirofiban Juno (from two 50 mL vials) to achieve a final concentration of 0.05 mg/mL. Mix well before administration.
2. Administer according to the appropriate dosage calculations above.
3. To reduce microbiological hazard, use as soon as practicable after dilution.
Discard any unused intravenous solution after 24 hours following start of infusion. If storage is necessary, hold at 2-8° C for not more than 24 hours.

4.3 Contraindications

Tirofiban is contraindicated in patients with:
Known hypersensitivity to any component of the product.
Active internal bleeding or a history of bleeding diathesis within the previous 30 days.
A history of intracranial haemorrhage, intracranial neoplasm, arteriovenous malformation, or aneurysm.
A history of thrombocytopenia following prior exposure to tirofiban.
History of stroke within 30 days or any history of haemorrhagic stroke.
Major surgical procedure (including epidural or spinal anaesthesia) or severe physical trauma within 1 month.
History, symptoms, or findings suggestive of aortic dissection.
Severe uncontrolled hypertension (systolic blood pressure > 180 mmHg and/or diastolic blood pressure > 110 mmHg).
Concomitant use of another parenteral GP IIb/IIIa inhibitor.
Acute pericarditis.

4.4 Special Warnings and Precautions for Use

Tirofiban should be used with caution in the following patients:
Recent (< 1 year) bleeding, including a history of gastrointestinal bleeding, or genitourinary bleeding of clinical significance.
Known coagulopathy, platelet disorder, or history of thrombocytopenia.
Platelet count < 150,000 cells/mm³.
History of cerebrovascular disease within 1 year.
Recent epidural procedure.
Haemorrhagic retinopathy.
Chronic haemodialysis.

Bleeding precautions.

Because tirofiban inhibits platelet aggregation, caution should be employed when it is used with other drugs that affect haemostasis. The safety of tirofiban when used in combination with thrombolytic agents has not been established.
During therapy with tirofiban, patients should be monitored for potential bleeding. When treatment of bleeding is required, discontinuation of the drug should be considered. Consideration may also be given to transfusions.
Fatal bleedings have been reported (see Section 4.8 Adverse Effects (Undesirable Effects)).

Femoral artery access site.

Tirofiban is associated with minor increases in bleeding rates particularly at the site of arterial access for femoral sheath placement. Care should be taken when attempting vascular access that only the anterior wall of the femoral artery is punctured, avoiding a Seldinger (through and through) technique for obtaining sheath access. Care should be taken to obtain proper haemostasis after removal of the sheaths followed by close observation.

Laboratory monitoring.

Platelet counts, and haemoglobin and haematocrit should be monitored prior to treatment, within 6 hours following the bolus or loading infusion, and at least daily thereafter during therapy with tirofiban (or more frequently if there is evidence of significant decline). In patients who have previously received GP IIb/IIIa receptor antagonists, consideration should be given to earlier monitoring of platelet count. If the patient experiences a platelet count decrease to < 90,000 cells/mm³, additional platelet counts should be performed to exclude pseudothrombocytopenia. If thrombocytopenia is confirmed, tirofiban and heparin should be discontinued and the condition appropriately monitored and treated.
In addition, the activated partial thromboplastin time (APTT) should be determined before treatment and the anticoagulant effects of heparin should be carefully monitored by repeated determinations of APTT and the dose adjusted accordingly (also see Section 4.2 Dose and Method of Administration). Potentially life-threatening bleeding may occur especially when heparin is administered with other products affecting haemostasis, such as GP IIb/IIIa receptor antagonists.

Use in renal impairment.

In clinical studies, patients with severe renal insufficiency (creatinine clearance < 30 mL/min) demonstrated decreased plasma clearance of tirofiban. The dosage of tirofiban should be reduced in these patients (see Section 4.2 Dose and Method of Administration; Section 5.1 Pharmacodynamic Properties, Clinical trials).

Paediatric use.

Safety and effectiveness in children have not been established.

Use in the elderly.

In clinical studies the efficacy of tirofiban in the elderly (≥ 65 years) was comparable to that seen in younger patients (< 65 years). Elderly patients receiving tirofiban with heparin or heparin alone had a higher incidence of bleeding complications than younger patients. The incremental risk of bleeding in patients treated with tirofiban in combination with heparin over the risk in patients treated with heparin alone was comparable regardless of age. The overall incidence of non-bleeding adverse events was higher in older patients (compared to younger patients); however, the incidence of non-bleeding adverse events in these patients was comparable between the tirofiban with heparin and the heparin alone groups. No dose adjustment is recommended (see Section 4.2 Dose and Method of Administration).
This drug is known to be excreted by the kidney. A 50% reduction in dose is recommended for patients with severe renal insufficiency (creatinine clearance < 30 mL/min) (see Section 4.2 Dose and Method of Administration; Section 4.4 Special Warnings and Precautions for Use). Plasma clearance of tirofiban is about 19 to 26% lower in elderly (> 65 years) patients with coronary artery disease compared to younger (≤ 65 years) patients.

Effect on laboratory tests.

The most frequently observed laboratory adverse events in patients receiving tirofiban concomitantly with heparin were related to bleeding. Decreases in haemoglobin and haematocrit, and platelet count were observed. Increases in the presence of urine and faecal occult blood were also observed.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Tirofiban has been studied on a background of aspirin and heparin.
The use of tirofiban, in combination with heparin and aspirin, has been associated with an increase in bleeding compared to heparin and aspirin alone (see Section 4.8 Adverse Effects (Undesirable Effects)). Caution should be employed when tirofiban is used with other drugs that affect haemostasis (e.g. warfarin) (see Section 4.4 Special Warnings and Precautions for Use, Bleeding precautions). The safety of tirofiban when used in combination with thrombolytic agents has not been established.
Tirofiban has been used concomitantly in clinical studies with beta-blockers, calcium channel blockers, non-steroidal anti-inflammatory drugs (NSAIDs) and nitrate preparations without evidence of clinically significant adverse interactions.
In a sub-set of patients (n=762) in the PRISM study, the plasma clearance of tirofiban in patients receiving one of the following drugs was compared to that in patients not receiving that drug. There were no clinically significant interactions of these drugs on the plasma clearance of tirofiban: acebutolol, alprazolam, amlodipine, aspirin preparations, atenolol, bromazepam, captopril, diazepam, digoxin, diltiazem, docusate sodium, enalapril, frusemide, glibenclamide, heparin, insulin, isosorbide, thyroxine sodium, lorazepam, lovastatin, metoclopramide, metoprolol, morphine, nifedipine, nitrate preparations, omeprazole, oxazepam, paracetamol, potassium chloride, propranolol, ranitidine, simvastatin, sucralfate and temazepam.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Fertility and reproductive performance were not affected in studies with male and female rats given intravenous doses of tirofiban up to 5 mg/kg/day.
(Category B1)
There are no adequate and well-controlled studies in pregnant women. Tirofiban should be used during pregnancy only if the potential benefit justifies the potential risk to the foetus.
Studies of developmental toxicity in rats and rabbits showed no evidence of maternal or foetal toxicity. In addition, a study of the potential developmental toxicity through sexual maturity of rats exposed in utero and during lactation showed no drug-related effects on mortality, growth, development, and sexual maturation of the F₁ generation. In the developmental toxicity studies, dams were given tirofiban intravenously at doses up to 5 mg/kg/day.
It is not known whether tirofiban is excreted in human milk, but it is excreted in rat milk. Because many drugs are excreted in human milk, and because of the potential for adverse effects on the nursing infant, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother. Tirofiban crosses the placenta in rats and rabbits.

4.7 Effects on Ability to Drive and Use Machines

The effects of this medicine on a person's ability to drive and use machines were not assessed as part of this registration.

4.8 Adverse Effects (Undesirable Effects)

Bleeding.

The most common drug-related adverse event reported during therapy with tirofiban when used concomitantly with heparin and aspirin, was bleeding, usually reported by the investigators as oozing or mild. (Also see Section 4.4 Special Warnings and Precautions for Use, Effect on laboratory tests.)
The incidences of major and minor bleeding using the TIMI** criteria in the PRISM PLUS (Platelet Receptor Inhibition for Ischaemic Syndrome Management - Patients Limited by Unstable Signs and Symptoms) study are shown in Table 2.

** Bovill, E.G.; et al: Haemorrhagic Events during Therapy with Recombinant Tissue-Type Plasminogen Activator, Heparin, and Aspirin for Acute Myocardial Infarction, Results of the Thrombolysis in Myocardial Infarction (TIMI), Phase II Trial, Annals of Internal Medicine, 115(4): 256-265, 1991.
There were no reports of intracranial bleeding in the PRISM PLUS study for tirofiban in combination with heparin or in the control group (which received heparin). In the PRISM PLUS Study, the incidences of retroperitoneal bleeding reported for tirofiban in combination with heparin, and for the control group were 0.0% and 0.1%, respectively.
Female patients and elderly patients receiving tirofiban with heparin or heparin alone had a higher incidence of bleeding complications than male patients or younger patients, respectively. The incremental risk of bleeding in patients treated with tirofiban in combination with heparin over the risk in patients treated with heparin alone was comparable regardless of age or gender. No dose adjustment is recommended for these populations (see Section 4.2 Dose and Method of Administration).

Thrombocytopenia.

Patients treated with tirofiban, with heparin, were more likely to experience decreases in platelet counts than the control group. These decreases were reversible upon discontinuation of tirofiban. The percentage of patients with a decrease of platelets to < 90,000 cells/mm³ was 1.5%. The percentage of patients with a decrease of platelets to < 50,000 cells/mm³ was 0.3%. Platelet decreases have been observed in patients with no prior history of thrombocytopenia upon readministration of GP IIb/IIIa receptor antagonists.

Other adverse reactions.

The most frequent drug-related non-bleeding adverse reactions reported with tirofiban, administered concomitantly with heparin, occurring at an incidence of > 1% were: nausea (1.7% v 1.4% control); fever (1.5% v 1.1% control); headache (1.1% v 1.2% control).
In clinical studies, the incidences of adverse events were generally similar among different races, patients with or without hypertension, patients with or without diabetes mellitus, and patients with or without hypercholesteremia.
The overall incidence of non-bleeding adverse events was higher in female patients (compared to male patients) and older patients (compared to younger patients). However, the incidences of non-bleeding adverse events in these patients were comparable between the tirofiban with heparin and the heparin alone groups. (See above for bleeding adverse events.)
The following additional adverse reactions have been reported in post-marketing experience:

Bleeding.

Intracranial bleeding, retroperitoneal bleeding, haemopericardium, pulmonary (alveolar) haemorrhage and spinal-epidural hematoma. Fatal bleedings have been reported rarely.

Body as a whole.

Acute and/or severe decreases in platelet counts which may be associated with chills, low-grade fever, or bleeding complications (see above).

Hypersensitivity.

Rash and urticaria. Severe allergic reactions including anaphylactic reactions. The reported cases have occurred during the first day of tirofiban infusion, during initial treatment, and during readministration of tirofiban. Some cases have been associated with severe thrombocytopenia (platelet counts < 10,000/mm³).

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at http://www.tga.gov.au/reporting-problems.

4.9 Overdose

Symptoms and signs.

In clinical trials, inadvertent overdosage with tirofiban occurred in doses up to 5 times and 2 times the recommended dose for bolus administration and loading infusion, respectively. Inadvertent overdosage occurred in doses up to 9.8 times the 0.15 microgram/kg/min maintenance infusion rate.
The most frequently reported manifestation of overdosage was bleeding, primarily minor mucocutaneous bleeding events and minor bleeding at the sites of cardiac catheterisation (see Section 4.4 Special Warnings and Precautions for Use, Bleeding precautions).

Management.

Overdosage of tirofiban should be treated by assessment of the patient's clinical condition and cessation or adjustment of the drug infusion as appropriate.
Tirofiban can be removed by haemodialysis.
For information on the management of overdose, contact the Poisons Information Centre on 13 11 26 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Platelet activation, adhesion and aggregation represent critical initiating steps in the formation of arterial thrombus overlying disrupted atherosclerotic plaque. Thrombus formation is central to the pathophysiology of the acute coronary ischaemic syndromes of unstable angina and myocardial infarction, as well as to cardiac ischaemic complications following coronary angioplasty.
Tirofiban is a non-peptide antagonist of the GP IIb/IIIa receptor, the major platelet surface receptor involved in platelet aggregation. Tirofiban prevents binding of fibrinogen to GP IIb/IIIa, thereby blocking the cross-linking of platelets and platelet aggregation.
Tirofiban causes potent inhibition of platelet function as demonstrated by its ability to inhibit ex vivo adenosine phosphate (ADP)-induced platelet aggregation and prolong bleeding time (BT) in healthy subjects and patients with coronary artery disease. The time course of inhibition parallels the plasma concentration profile of the drug. Following discontinuation of an infusion of tirofiban, platelet function rapidly returns to baseline.
Co-administration of a 4-hour infusion of 0.15 microgram/kg/min of tirofiban and aspirin results in the anticipated near maximal inhibition of platelet aggregation and a modest additive effect of BT prolongation.
In patients with unstable angina, a two-staged intravenous infusion regimen of tirofiban (loading infusion of 0.4 microgram/kg/min for 30 minutes followed by 0.1 microgram/kg/min for up to 48 hours in the presence of heparin and aspirin), produces approximately 90% inhibition of ex vivo ADP-induced platelet aggregation with a 2.9-fold prolongation of bleeding time during the infusion. Inhibition was achieved rapidly with the 30-minute loading infusion and was maintained over the duration of the infusion.

Clinical trials.

Unstable angina/non-Q-wave myocardial infarction.

PRISM-PLUS (Platelet Receptor Inhibition for Ischaemic Syndrome Management - Patients Limited by Unstable Signs and Symptoms).

In the multi-centre, randomised, parallel, double-blind PRISM-PLUS trial, the use of tirofiban in combination with heparin versus heparin alone was evaluated in patients with documented unstable angina/non-Q-wave myocardial infarction.
In this study, patients were randomised to either tirofiban (30 minute loading infusion of 0.4 microgram/kg/min followed by a maintenance infusion of 0.10 microgram/kg/min) and heparin (bolus of 5,000 units (U) followed by an infusion of 1,000 U/hr titrated to maintain an activated partial thromboplastin time (APTT) of approximately 2 times control), or heparin alone (bolus of 5,000 U followed by an infusion of 1,000 U/hr titrated to maintain an APTT of approximately 2 times control). A third group of patients was initially randomised to tirofiban (30 minute loading dose of 0.6 microgram/kg/min followed by a maintenance infusion of 0.15 microgram/kg/min) with no heparin. This arm was discontinued when an increase in mortality was noted at seven days [16 deaths (4.6%) with tirofiban, as compared with 4 deaths (1.1%) with heparin].
All patients received concomitant aspirin unless contraindicated. Therapy with tirofiban commenced within 12 hours of the last episode of chest pain. Patients underwent 48 hours of medical stabilisation on study drug therapy, after which angiography and angioplasty/atherectomy remained options while continuing on tirofiban. Tirofiban was generally administered for a minimum of 48 hours and was continued up to 108 hours; on average, patients received tirofiban for 71.3 hours.
The primary endpoint of the study was a composite of refractory ischaemia, new myocardial infarction and death at 7 days following initiation of tirofiban. At the primary endpoint, there was a 31.6% risk reduction in the composite, a 46.6% risk reduction in myocardial infarction, and a 42.8% risk reduction in the composite of myocardial infarction and death. The results are shown in Table 3.

At 30 days, the risk of the composite endpoint was reduced by 22% (p=0.029) and there was a 30% reduction in the composite of death and myocardial infarction (p=0.027).
At 6 months, the risk of the composite endpoint was reduced by 18.9% (p=0.024); in addition, there was 22.5% risk reduction in the composite of myocardial infarction and death. The risk reduction in the composite endpoint at 7 days, 30 days and 6 months is shown in the Kaplan-Meier curve in Figure 1.

In the 30% of patients who underwent angioplasty/atherectomy in the PRISM-PLUS study, there was a 45.7% risk reduction in the composite endpoint following the procedure at day 30 after start of study drug, as well as a 43.2% risk reduction in the composite of death and myocardial infarction.
A sub-study in PRISM-PLUS found that there was a significant decrease in the extent of angiographically apparent thrombus in patients treated with tirofiban in combination with heparin compared to heparin alone. In addition, flow in the affected coronary artery was significantly improved.
PRISM-PLUS was not designed to provide definitive results in subsets of the overall population. Nonetheless, demographic results were examined for age, gender and race. No difference in benefit was noticed for age and gender but too few non-Caucasians were enrolled to make a definite statement about racial differences in treatment effect.

PRISM (Platelet Receptor Inhibition for Ischaemic Syndrome Management).

In the PRISM study, a randomised, parallel, double-blind, active control study, tirofiban alone (n=1616) was compared to heparin (n=1616) alone as medical management in patients with unstable angina/non-Q-wave myocardial infarction. In this study, the drug was started within 24 hours of the time the patient experienced chest pain.
Patients were randomised to either tirofiban alone (30 minute loading dose of 0.6 microgram/kg/min, followed by a maintenance infusion of 0.15 microgram/kg/min) or heparin alone (bolus of 5,000 U followed by an infusion of 1000 U/hr titrated to maintain an APTT of approximately 2 times control). The mean age of the population was 62 years; 32% of the population was female and 25% had non-Q-wave myocardial infarction on presentation. Thirty percent had no ECG evidence of cardiac ischaemia. Exclusion criteria were similar to PRISM-PLUS. The primary, prospectively identified endpoint was the composite endpoint of refractory ischaemia, myocardial infarction or death after a 48-hour drug infusion with tirofiban. The results are shown in Table 4.

In the PRISM study, no adverse effect of tirofiban on mortality at either 7 or 30 days was detected.

5.2 Pharmacokinetic Properties

Distribution.

Tirofiban is not highly bound to plasma proteins and protein binding is concentration independent over the range of 0.01 to 25 microgram/mL. Unbound fraction in human plasma is 35%. The steady state volume of distribution of tirofiban ranges from 22 to 42 litres.

Metabolism.

Profiling of ¹⁴C-labelled tirofiban in urine and faeces indicates that the radioactivity was accounted for mainly by unchanged tirofiban. Circulating plasma radioactivity is accounted for mainly by unchanged tirofiban (up to 10 hours postdose). These data suggest limited metabolism of tirofiban.

Excretion.

Following an intravenous dose of ¹⁴C-labelled tirofiban in healthy subjects, 66% of radioactivity is recovered in the urine and 23% in the faeces. Total radioactivity recovery is about 91%. Both urinary and biliary excretion contribute significantly to the elimination of tirofiban.
In healthy subjects, the plasma clearance of tirofiban ranges from 213 to 314 mL/min. Renal clearance accounts for 39 to 69% of plasma clearance. Half-life ranges from 1.4 to 1.8 hours.
In patients with coronary artery disease, the plasma clearance of tirofiban ranges from 152 to 267 mL/min. Renal clearance accounts for 39% of plasma clearance. Half-life ranges from 1.9 to 2.2 hours.

Characteristics in patients.

Gender.

Plasma clearance of tirofiban in patients with coronary artery disease is similar in males and females.

Elderly.

Plasma clearance of tirofiban is about 19 to 26% lower in elderly (> 65 years) patients with coronary artery disease compared to younger (≤ 65 years) patients.

Race.

No difference in plasma clearance was detected in patients of different races.

Hepatic insufficiency.

In patients with mild to moderate hepatic insufficiency, plasma clearance of tirofiban is not significantly different compared to healthy subjects.

Renal insufficiency.

Plasma clearance of tirofiban is lower to a clinically significant extent (> 50%) in patients with creatinine clearance < 30 mL/min, including patients requiring haemodialysis (see Section 4.2 Dose and Method of Administration, Patients with severe renal insufficiency). Tirofiban is removed by haemodialysis.

5.3 Preclinical Safety Data

Genotoxicity.

Tirofiban was not genotoxic in a series of assays for gene mutations (Salmonella typhimurium, Escherichia coli and Chinese hamster lung cells), chromosomal aberrations (Chinese hamster ovary cell in vitro and mouse bone marrow in vivo) or DNA damage (alkaline elution assay).

Carcinogenicity.

The carcinogenic potential of tirofiban has not been evaluated.

6 Pharmaceutical Particulars

6.1 List of Excipients

See Section 2 Qualitative and Quantitative Composition.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 25°C. Do not freeze. Protect from light during storage.

6.5 Nature and Contents of Container

Tirofiban Juno Concentrate for Infusion is a clear, colourless sterile solution provided as 12.5 mg/50 mL in 50 mL glass vials.
Must be diluted prior to administration (see Instructions for use), to give a concentration of 0.05 mg/mL.

Pack size.

Packs of 1 vial.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of in accordance with local requirements.

6.7 Physicochemical Properties

Chemical name.

Tirofiban Juno (tirofiban hydrochloride, MSD), a non-peptide antagonist of the platelet glycoprotein (GP) IIb/IIIa receptor, is a platelet aggregation inhibitor.
Tirofiban hydrochloride monohydrate is chemically described as N-(butylsulfonyl)-O-[4-(4-piperidinyl) butyl]-L-tyrosine monohydrochloride monohydrate.
Tirofiban hydrochloride monohydrate is a white to off-white non-hygroscopic free-flowing powder. It is very slightly soluble in water.
The pKa for the acid is 3.17 and for the base is 10.21.

Empirical formula.

C₂₂H₃₆N₂O₅S.HCl.H₂O.

Molecular weight.

495.07.

Chemical structure.

CAS number.

150915-40-5.

7 Medicine Schedule (Poisons Standard)

S4 - Prescription only Medicine.

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