Parenteral anticoagulants BNF 57

2.8.1 Parenteral anticoagulants BNF 57

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BNF 57

2.8.1 Parenteral anticoagulants 125

Heparin (Non-proprietary) A 17 500 units/mL, 3500-unit (0.2-mL) prefilled syringe Injection , heparin sodium 1000 units/mL, net price 1-

mL amp = 37p, 5-mL amp = 93p, 5-mL vial = 92p, 10- Dose prophylaxis of deep-vein thrombosis, by subcutaneous mL amp = £1.60, 20-mL amp = £2.63; 5000 units/mL,

injection , moderate risk, 2500 units 2 hours before or 6 hours after 1-mL amp = 72p, 5-mL amp = £1.87, 5-mL vial =

surgery then 2500 units every 24 hours for 7–10 days; high risk, £2.09; 25 000 units/mL, 1-mL amp = £1.90, 5-mL vial

3500 units 2 hours before or 6 hours after surgery then 3500 units = £3.68 every 24 hours for 7–10 days Prevention of clotting in extracorporeal circuits, consult product

Monoparin c (CP) A literature Injection , heparin sodium (mucous) 1000 units/mL,

Injection , bemiparin sodium 25 000 units/mL, net net price 1-mL amp = 28p; 5-mL amp = 52p; 10-mL

price 0.2-mL (5000-unit) prefilled syringe = £4.22, 0.3- amp = 69p; 20-mL amp = £1.24; 5000 units/mL, 1-mL

mL (7500-unit) prefilled syringe = £5.34, 0.4-mL amp = 54p; 5-mL amp = 74p; 25 000 units/mL, 0.2-

(10 000-unit) prefilled syringe = £8.44 mL amp = 46p, 1-mL amp = £1.52

Dose treatment of deep-vein thrombosis (with or without pulmonary embolism), by subcutaneous injection , 115 units/kg Monoparin Calcium c (CP) A every 24 hours for 5–9 days (and until adequate oral anti-

Injection , heparin calcium 25 000 units/mL, net price coagulation established) 0.2-mL amp = 73p Multiparin c (CP) A

Injection , heparin sodium (mucous) 1000 units/mL, net price 5-mL vial = 70p; 5000 units/mL, 5-mL vial =

DALTEPARIN SODIUM

£1.57; 25 000 units/mL, 5-mL vial = £5.93 Indications see notes above and under preparations

Excipients include benzyl alcohol (avoid in neonates, see Excipients, p. 2)

Cautions see under Heparin and notes above Contra-indications see under Heparin Side-effects see under Heparin

Low molecular weight heparins

Dose

Low molecular weight heparins

(bemiparin,

. See under preparations below

dalteparin, enoxaparin, and tinzaparin) are usually

Fragmin preferred over unfractionated heparin in the prevention c (Pharmacia) A ardiov C

of venous thromboembolism because they are as effec- Injection (single-dose syringe), dalteparin sodium tive and they have a lower risk of heparin-induced

12 500 units/mL, net price 2500-unit (0.2-mL) syringe

thrombocytopenia. Also, the standard prophylactic regi- = £1.86; 25 000 units/mL, 5000-unit (0.2-mL) syringe men does not require monitoring. In orthopaedic prac-

ascular

= £2.82, 7500-unit (0.3-mL) syringe = £4.23, 10 000- tice low molecular weight heparins are probably more

unit (0.4-mL) syringe = £5.65, 12 500-unit (0.5-mL) effective than unfractionated heparin; fondaparinux

syringe = £7.06, 15 000-unit (0.6-mL) syringe = £8.47,

syst

(p. 128) can also be used. The duration of action of

18 000-unit (0.72-mL) syringe = £10.16 Dose low molecular weight heparins is longer than that of prophylaxis of deep-vein thrombosis, in surgical patients, by subcutaneous injection , moderate risk, 2500 units 1–2 hours

em

unfractionated heparin; once-daily subcutaneous dosage before surgery then 2500 units every 24 hours for 5–7 days or means that they are convenient to use.

longer; high risk, 2500 units 1–2 hours before surgery, then 2500 units 8–12 hours later (or 5000 units on the evening before

Low molecular weight heparins are also used in the surgery, then 5000 units on the following evening), then 5000 units treatment of deep-vein thrombosis, pulmonary embo-

every 24 hours for 5–7 days or longer (5 weeks in hip replace- lism, myocardial infarction (section 2.10.1), unstable

ment)

coronary artery disease (section 2.6) and for the pre- Prophylaxis of deep-vein thrombosis in medical patients, by vention of clotting in extracorporeal circuits.

subcutaneous injection , 5000 units every 24 hours Treatment of deep-vein thrombosis and of pulmonary embolism,

Routine monitoring of anti-Factor Xa activity is not by subcutaneous injection , as a single daily dose, ADULT body- usually required during treatment with low molecular

weight under 46 kg, 7500 units daily; body-weight 46–56 kg, weight heparins, but may be necessary in patients at

10 000 units daily; body-weight 57–68 kg, 12 500 units daily; body- weight 69–82 kg, 15 000 units daily; body-weight 83 kg and over, increased risk of bleeding (e.g. in renal impairment and

18 000 units daily, with oral anticoagulant treatment until those who are underweight or overweight).

prothrombin complex concentration in therapeutic range (usually for at least 5 days); monitoring of anti-Factor Xa not usually

Haemorrhage required; for patients at increased risk of haemorrhage, see below

See under Heparin.

Treatment of venous thromboembolism in pregnancy [unlicensed indication], by subcutaneous injection , early pregnancy body-

Pregnancy See under Heparin.

weight under 50 kg, 5000 units twice daily; body-weight 50–70 kg, 6000 units twice daily; body-weight 70–90 kg, 8000 units twice daily; body-weight over 90 kg, 10 000 units twice daily

Injection , dalteparin sodium 2500 units/mL (for sub- Indications see notes above and under preparations

BEMIPARIN SODIUM

cutaneous or intravenous use), net price 4-mL Cautions

(10 000-unit) amp = £5.12; 10 000-units/mL (for sub- see under Heparin and notes above

cutaneous or intravenous use), 1-mL (10 000-unit) Contra-indications see under Heparin; breast-feeding

amp = £5.12; 25 000 units/mL (for subcutaneous use (Appendix 5)

only), 4-mL (100 000-unit) vial = £48.66 Side-effects see under Heparin

Dose treatment of deep-vein thrombosis and of pulmonary Dose

embolism, by subcutaneous injection , 200 units/kg (max. . See under preparations below

18 000 units) as a single daily dose (or 100 units/kg twice daily if increased risk of haemorrhage) with oral anticoagulant treatment

Zibor c (Amdipharm) TA until prothrombin complex concentration in therapeutic range Injection (usually for at least 5 days) , bemiparin sodium 12 500 units/mL, net Note For monitoring, blood should be taken 3–4 hours after a dose price 2500-unit (0.2-mL) prefilled syringe = £1.86;

(recommended plasma concentration of anti-Factor Xa 0.5–

2.8.1 Parenteral anticoagulants BNF 57

1 unit/mL); monitoring not required for once-daily treatment

Dose

regimen and not generally necessary for twice-daily regimen Unstable coronary artery disease, by subcutaneous injection ,

. See under preparations below 120 units/kg every 12 hours (max. 10 000 units twice daily) for 5–

Innohep 8 days c (LEO) A Prevention of clotting in extracorporeal circuits, consult product

Injection , tinzaparin sodium 10 000 units/mL, net literature

price 2500-unit (0.25-mL) syringe = £1.98, 3500-unit Injection (graduated syringe), dalteparin sodium

(0.35-mL) syringe = £2.77, 4500-unit (0.45-mL)

10 000 units/mL, net price 1-mL (10 000-unit) syringe syringe = £3.56, 20 000-unit (2-mL) vial = £10.56 = £5.65

Dose prophylaxis of deep-vein thrombosis, by subcutaneous injection

Dose unstable coronary artery disease (including non-ST-seg- , general surgery, 3500 units 2 hours before surgery, then ment-elevation myocardial infarction), by subcutaneous injec-

3500 units every 24 hours for 7–10 days; orthopaedic surgery, tion , 120 units/kg every 12 hours (max. 10 000 units twice daily)

50 units/kg 2 hours before surgery, then 50 units/kg every 24 for up to 8 days; beyond 8 days (if awaiting angiography or

hours for 7–10 days or 4500 units 12 hours before surgery, then revascularisation) women body-weight less than 80 kg and men

4500 units every 24 hours for 7–10 days less than 70 kg, 5000 units every 12 hours, women body-weight

Prevention of clotting in extracorporeal circuits, consult product greater than 80 kg and men greater than 70 kg, 7500 units every

literature

12 hours, until day of procedure (max. 45 days) Injection , tinzaparin sodium 20 000 units/mL, net

tem price 0.5-mL (10 000-unit) syringe = £8.98, 0.7-mL

sys ENOXAPARIN SODIUM

(14 000-unit) syringe = £12.57, 0.9-mL (18 000-unit)

syringe = £16.16, 2-mL (40 000-unit) vial = £34.20 Indications see notes above and under preparations

Dose treatment of deep-vein thrombosis and of pulmonary embolism, by subcutaneous injection , 175 units/kg once daily for

Cautions see under Heparin and notes above; low at least 6 days (and until adequate oral anticoagulation estab-

ascular

body-weight (increased risk of bleeding)

lished)

Contra-indications see under Heparin; breast-feeding Treatment of venous thromboembolism in pregnancy [unlicensed

diov

(Appendix 5) indication], by subcutaneous injection , 175 units/kg once daily

ar Note C Treatment regimens do not require anticoagulation mon-

Side-effects see under Heparin

itoring

Asthma 2 Presence of sulphites in formulation may (especially in

Dose

. See under preparation below patients with asthma) lead to hypersensitivity (with broncho- spasm and shock)

Clexane c (Rhoˆne-Poulenc Rorer) A Injection , enoxaparin sodium 100 mg/mL, net price 20-mg (0.2-mL, 2000-units) syringe = £3.15, 40-mg (0.4-mL, 4000-units) syringe = £4.20, 60-mg (0.6-mL,

Heparinoids

6000-units) syringe = £4.75, 80-mg (0.8-mL, 8000- Danaparoid is a heparinoid used for prophylaxis of units) syringe = £5.40, 100-mg (1-mL, 10 000-units)

deep-vein thrombosis in patients undergoing general syringe = £6.69; 300 mg (3-mL, 30 000-units) vial

or orthopaedic surgery. Providing there is no evidence (Clexane c Multidose ) = £22.20; 150 mg/mL (Clexane c of cross-reactivity, it also has a role in patients who

Forte ), 120-mg (0.8-mL, 12 000-units) syringe = £9.77, develop thrombocytopenia in association with heparin. 150-mg (1-mL, 15 000-units) syringe = £11.10

Dose prophylaxis of deep-vein thrombosis especially in surgical patients, by subcutaneous injection , moderate risk, 20 mg

DANAPAROID SODIUM

Indications prevention of deep-vein thrombosis in paedic surgery), 40 mg (4000 units) 12 hours before surgery then

(2000 units) approx. 2 hours before surgery then 20 mg (2000 units) every 24 hours for 7–10 days; high risk (e.g. ortho-

general or orthopaedic surgery; thromboembolic dis- 40 mg (4000 units) every 24 hours for 7–10 days

ease in patients with history of heparin-induced Prophylaxis of deep-vein thrombosis in medical patients, by subcutaneous injection , 40 mg (4000 units) every 24 hours for at

thrombocytopenia least 6 days and continued until patient ambulant (max. 14 days)

Cautions recent bleeding or risk of bleeding; conco- Treatment of deep-vein thrombosis or pulmonary embolism, by

mitant use of drugs that increase risk of bleeding; subcutaneous injection , 1.5 mg/kg (150 units/kg) every 24 hours,

antibodies to heparins (risk of antibody-induced usually for at least 5 days (and until adequate oral anticoagulation established)

thrombocytopenia); body-weight over 90 kg (monitor Unstable angina and non-ST-segment-elevation myocardial

anti factor Xa activity); hepatic impairment (Appendix infarction, by subcutaneous injection , 1 mg/kg (100 units/kg)

2); renal impairment (Appendix 3); pregnancy every 12 hours usually for 2–8 days (minimum 2 days)

(Appendix 4); breast-feeding (Appendix 5) Prevention of clotting in extracorporeal circuits, consult product

Contra-indications haemophilia and other haemor- literature

rhagic disorders, thrombocytopenia (unless patient Treatment of venous thromboembolism in pregnancy [unlicensed indication], by subcutaneous injection , early pregnancy body-

has heparin-induced thrombocytopenia), recent weight under 50 kg, 40 mg (4000 units) twice daily; body-weight

cerebral haemorrhage, severe hypertension, active 50–70 kg, 60 mg (6000 units) twice daily; body-weight 70–90 kg,

peptic ulcer (unless this is the reason for operation), 80 mg (8000 units) twice daily; body-weight over 90 kg, 100 mg

diabetic retinopathy, acute bacterial endocarditis, (10 000 units) twice daily

spinal or epidural anaesthesia with treatment doses of danaparoid