Anticoagulation

Heparin dosing
- Prophylaxis: 5000 U SC Q8-12H
- Treatment: 80 U/kg bolus; 18 U/kg/hr infusion
- ACS: 60 U/kg bolus; 12 U/kg/hr infusion
Heparin antidote

Protamine
Enoxaparin prophylaxis dosing
- 30 mg SC Q12H or 40 mg SC daily
- CrCl < 30ml/min: 30 mg SC daily
Enoxaparin treatment dosing
- 1mg/kg SC Q12H or 1.5mg/kg SC daily
- CrCl < 30ml/mmin: 1 mg/kg SC daily
May cause osteoporosis with long term use

Heparin
Selectively inhibits Factor Xa
- Fondaparinux (SC)
- Rivaroxaban (PO)
Direct thrombin inhibitors
- Lepirudin (IV)
- Argatroban (IV)
- Bivalirudin (IV)
- Dabigatran (PO)
Dabigatran dosing

150mg BID; 75mg BID if CrCl 15-30 ml/min
INR < 5.0 with no significant bleeding

Lower dose or omit dose, monitor more frequently
INR >= 5.0 but < 9.0 and no significant bleeding
- Omit 1-2 doses, monitor more frequently OR
- Omit 1 dose and give PO Vitamin K 1-2.5mg
INR >= 9.0 and no significant bleeding

Hold warfarin, give PO Vitamin K 2.5-5mg
Serious bleeding and elevated INR

Hold warfarin and give 10mg Vitamin K by slow IV infusion

Author

adguvetis

162129

Card Set

Anticoagulation

Description

Naplex

Updated

2012-07-11T21:29:32Z