-
Heparin DVT Prevention
- Dose 5000 IU SQ Q8-12H
- Q8H High risk
-
Heparin DVT/ PE Tx
- Bolus 80 U/kg (max 10K)
- Infusion 18 U/kg/hr (2.3k U/hr)
-
Heparin Protamine Dosing
1mg = 100 units
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Enoxaparin (lovenox) Prevention DVT - Med pt
- 40mg SQ QD
- < 30 ml/min
- 30mg SQ QD
-
Enoxaparin (lovenox) Prevention DVT - Hip
- 30mg SQ Q12 or 40mg SQ QD
- < 30 ml/min
- 30mg SQ QD
-
Enoxaparin (lovenox) Prevention DVT - Knee Replacement
- 30mg SQ Q12
- < 30 ml/min
- 30mg SQ QD
-
Enoxaparin (lovenox) Prevention DVT - abdominal Surgery
- 40mg SQ QD
- < 30 ml/min
- 30mg SQ QD
-
Dalterparin (fragmin) Prevention DVT - Abdominal surgery
- 2.5K IU SQ QD
- 1-2 hours post surgery
-
Dalterparin (fragmin) Prevention DVT - abdominal Surgery High VTE
- 5K IU SQ QD
- Q12H post surgery
-
Dalterparin (fragmin) Prevention DVT - Med Pt
5k IU SQ QD
-
Dalterparin (fragmin) Prevention DVT - Hip
- 5K IU SQ
- Q12H post/ pre op QD
-
Enoxaparin VTE Tx
- 1mg/kg SQ Q12H or
- 1.5mg/kg SQ QD
- < 30ml/min
- 1mg/kg SQ QD
-
Tinzaparin (Innohep) VTE Tx
- VTE 175 IU/kg SQ QD
- CI under <30ml/min
-
Fonadparinux (arixtra) - Surgery Prophylaxis
- 2.5 mg Q6-8 before
- CI < 30ml/min, BW < 50kg
-
Fonadparinux (arixtra) Tx < 50 kg
- 5 mg SQ QD
- CI Renal < 30ml/min
-
Fonadparinux (arixtra) Tx 50 - 100 kg
- 7.5 mg SQ QD
- CI Renal < 30ml/min
-
Fonadparinux (arixtra) Tx 100 + kg
- 10 mg SQ QD
- CI Renal < 30ml/min
-
Warfarin Tx
- 5-10 mg PO Young
- 2.5 - 5 mg Old, Surgery Pt
- CI Pregnant
-
Rivaroxaban (Xarelto) Post Op VTE Prophylaxis
-
Rivaroxaban (Xarelto) Tx and 2nd Prophylaxis
- 15mg BID w/food x21D
- 20 mg QD w/food Duration therapy
- CI < 30ml/min
-
Rivaroxaban (Xarelto) Tx Afib
- 20mg PO Qpm
- 15-30 ml/min 15mg PO Qpm
-
Rivaroxaban (Xarelto) Tx Knee
10mg QD x 12D
-
Rivaroxaban (Xarelto) Tx Hip
10mg QD x 35D
-
Rivaroxaban (Xarelto) Liver Dosing
CI B and C
-
Rivaroxaban (Xarelto) Food dosing
- 10mg w/o food
- 10+ mg w/food
-
Argatroban Infusion
2 mcg/kg/min
-
Argatroban Infusion > 6 Liver dosing
0.5 mcg/kg/min
-
Argatroban Infusion HF
0.5 - 1.2 mcg/kg/min
-
Apixaban (Eliquis) - Stroke prophylaxis
5mg BID
-
Apixaban (Eliquis) reduced dose
- 2.5 mg PO BID
- Strong CYP3A4 inhibitor, 80+ y/o, BW < 60kg, SCr > 1.5
-
Dabigatran (Pradaxa) CrCl > 30 ml/min
150 mg BID
-
Dabigatran (Pradaxa) CrCl 15 - 30ml/min
75 mg BID
-
Dabigatran (Pradaxa) < 15 ml/min
No use
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