Table 222 Agents and dosing

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Route of administration: Subcutaneous or intravenous

Prophylactic: 5,000 units tid

Therapeutic: Bolus 5-10,000 units followed by 1-2,000 units/hour to achieve heparin levels of 0.35-0.7 anti-Xa units Low Molecular Weight Heparin Daltaparin

Prophylactic: 2500 units qday (low risk); 5000 units q day (high-risk abdominal surgery)

Therapy: 100 units/kg every 12 hours Enoxaparin

Prophylactic: 40 mg/day or 30 mg every 12 hours (orthopedic indications)

Therapy: 1 mg/kg every 12 hours or 1.5 mg/kg in low risk patients Nadroparin

Prophylactic: 2850 units every 24 hours (38 units/kg in high risk patients)

Therapy: 86 units/kg every 12 hours or 171 units/kg every 24 hours Tinzaparin

Prophylactic: 3500 units every 24 hours (4500 units in high risk patients)

Therapy: 175 units every 24 hours Pentasaccharide Fondaparinux

Prophylaxis: 2.5 mg every 24 hours

Therapy: 7.5 mg every 24 hours (consider 5.0 mg in patients under 50kg and 10 mg in patients over 100 kg)

For acute venous thrombosis the approved doses are either enoxaparin 1 mg/kg every 12 hours or tinzaparin 175 ^/kg every day (see Table 22.2 for all LMWH doses). For low-risk patients (calf vein thrombosis, upper extremity thrombosis), once-a-day therapy with 1.5 mg/kg of enoxaparin can be used, but this may not be adequate for higher-risk patients and twice a day therapy should be used. One trial did demonstrate that once daily dalteparin was inferior to twice a day therapy for venous disease and this dosing should not be used. For short courses of therapy, most patients do not need to have LMW heparin levels drawn. Patients who are very obese (>two times ideal body weight), who have severe liver or heart failure, who are pregnant, or on long-term LMWH therapy should have levels performed.

LMWH are renally cleared and the dose needs to be adjusted for renal function. For patients with creatinine clearance between 10-30 cc/hr the dose of enoxaparin is 0.65 mg/kg q12 hours. In patients on dialysis or with creatinine clearances less that 30 cc, the dose of enoxaparin should be 1 mg/kg/day. The pharmacokinetics of LMWH are not affected by weight and there should be no capping or adjusting of doses for overweight patients. Levels are drawn four hours after injection and the therapeutic range for enoxaparin is 0.7-1.2 anti-Xa units. Therapeutic ranges for other low molecular heparins have not been as well established.

The LMW heparins can be used in either inpatient or outpatient settings. Although LMW heparin is more expensive, inpatient savings can be realized since multiple aPTT's, daily platelet counts, and continuous intravenous therapy are not needed. In addition, it was in the general inpatient population that clinical trials demonstrated LMW heparin's effectiveness and safety over that of standard heparin.

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