Butorphanol Tartrate and Vorapaxar Sulfate

• Generic Name: butorphanol
• Dosage Forms: n.a.
• Other Brand Names: Stadol, Stadol NS

Relief of pain that is severe enough to require an opiate analgesic and for which alternative treatment options (e.g., nonopiate analgesics) have not been, or are not expected to be, adequate or tolerated.

Preoperative sedation and analgesia and as a supplement to surgical anesthesia.

Obstetric analgesia during labor.

Management of pain associated with migraine headache.

In equianalgesic doses, parenteral butorphanol is as effective as morphine, meperidine, and pentazocine, but relative potential for abuse reportedly is less than that of codeine or propoxyphene.

In symptomatic treatment of acute pain, reserve opiate analgesics for pain resulting from severe injuries, severe medical conditions, or surgical procedures, or when nonopiate alternatives for relieving pain and restoring function are expected to be ineffective or are contraindicated. Use smallest effective dosage for shortest possible duration since long-term opiate use often begins with treatment of acute pain. Optimize concomitant use of other appropriate therapies. (See Managing Opiate Therapy for Acute Pain under Dosage and Administration.)

• Generic Name: vorapaxar
• Dosage Forms: n.a.
• Other Brand Names: Zontivity

Reduction of the risk of thrombotic cardiovascular events (e.g., cardiovascular death, MI, stroke, urgent coronary revascularization) in patients with a history of MI or with peripheral arterial disease (PAD).

Use in conjunction with aspirin and/or clopidogrel; data lacking on use of vorapaxar in combination with other antiplatelet agents (e.g., prasugrel, ticagrelor) or as monotherapy.

Efficacy and safety established in patients with stable atherosclerotic disease; favorable benefit versus risk not established in the setting of acute coronary syndrome (ACS). (See Acute Coronary Syndrome under Uses.)

The American Heart Association (AHA), American College of Cardiology Foundation (ACCF), American College of Chest Physicians (ACCP), and other experts recommend long-term antiplatelet therapy (e.g., aspirin and/or clopidogrel) in patients with established coronary artery disease. Long-term antiplatelet therapy (e.g., clopidogrel, aspirin) also recommended in patients with symptomatic PAD, including those with intermittent claudication, critical limb ischemia, or prior revascularization or amputation of the lower extremity. When added to aspirin and/or clopidogrel therapy, vorapaxar reduces cardiovascular events (e.g., composite outcome of cardiovascular death, MI, stroke, and urgent coronary revascularization) but increases risk of bleeding, including intracranial hemorrhage.

Balance incremental benefits against risk of bleeding; certain patients (e.g., those with a history of MI who are at high risk of recurrence but low risk of bleeding and who have not had a previous stroke or TIA) may have greater potential for net clinical benefits. Overall risk-benefit of vorapaxar in routine clinical practice remains to be fully elucidated.

Has been used in patients with ACS; however, current evidence suggests that the addition of vorapaxar to standard antiplatelet therapy in such patients does not substantially reduce rate of ischemic events but substantially increases risk of clinically important bleeding.

Many clinicians currently advise against use of vorapaxar in patients with ACS.