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Fragmin
dalteparin
Black Box Warnings .
Spinal/Epidural Hematomas
may occur in anticoagulated pts receiving neuraxial anesthesia or spinal puncture; hematoma may result in long-term or permanent paralysis; incr. hematoma risk if indwelling epidural catheter use, concomitant use of drugs affecting hemostasis incl. NSAIDs, platelet inhibitors, or other anticoagulants, traumatic or repeated epidural or spinal puncture hx, spinal deformity, or spinal surgery hx; weigh risk/benefit before neuraxial intervention in anticoagulated pts or planned anticoagulation for thromboprophylaxis; administer 1st postop prophylactic dose (2500 units) 6-8h after procedure; administer 2nd postop prophylactic dose (2500 units or 5000 units) >24h after 1st dose; while optimal timing to minimize risk is unknown, delay spinal catheter placement or removal >12h after 2500 units qd, >15h after 5000 units qd, and >24h after tx doses (200 units/kg qd or 120 units/kg bid); consider delaying post-procedural dose >4h after catheter removal; for pts w/ CrCl <30, consider delaying spinal catheter placement or removal >24h after prophylactic doses (2500 units qd or 5000 units qd) and >48h after tx doses (200 units/kg qd or 120 units/kg bid); monitor s/sx neurologic impairment frequently, treat urgently if needed
Adult Dosing .
Dosage forms: INJ (pre-filled syringe): 2500 units per 0.2 mL, 5000 units per 0.2 mL, 7500 units per 0.3 mL, 10,000 units per mL, 12,500 units per 0.5 mL, 15,000 units per 0.6 mL, 18,000 units per 0.72 mL, INJ (vial): 2500 units per mL, 25,000 units per mL
DVT prophylaxis, hip replacement
- [postop start]
- Dose: 5000 units SC qd x10-14 days; Start: 2500 units SC x1 dose 4-8h postop; Info: allow >6h between 1st and 2nd doses
- [preop start, day of procedure]
- Dose: 5000 units SC qd x10-14 days; Start: 2500 units SC x1 dose <2h preop, then 2500 units SC x1 dose 4-8h postop; Info: allow >6h between 1st postop dose and 1st daily dose
- [preop start, evening before procedure]
- Dose: 5000 units SC qd x10-14 days; Start: 5000 units SC x1 dose 10-14h preop, then 5000 units SC x1 dose 4-8h postop; Info: allow 24h between preop and 1st postop doses
DVT prophylaxis, abdominal surgery
- [high risk pts]
- Dose: 5000 units SC qd x5-10 days; Start: evening before surgery; Alt: start 2500 units SC x1 dose 1-2h preop, then 2500 units SC x1 dose 12h later, then 5000 units SC qd x5-10 days
- [all other pts]
- Dose: 2500 units SC qd x5-10 days; Start: 1-2h preop
DVT prophylaxis, restricted mobility
- [5000 units SC qd x12-14 days]
DVT/PE extended tx, cancer pts
- [200 units/kg/dose SC qd x1mo, then 150 units/kg/dose SC qd x5mo]
- Max: 18,000 units/day; Info: for initial tx and recurrence prevention; may extend tx duration if benefit outweighs risk; decr. dose by 2500 units/day if Plt 50,000-100,000; D/C if Plt <50,000
angina, unstable
- [120 units/kg/dose SC q12h x5-8 days]
- Max: 10,000 units/dose; Info: for ischemic complications prophylaxis; cont. tx until pt stabilized; give w/ aspirin
NQWMI
- [120 units/kg/dose SC q12h x5-8 days]
- Max: 10,000 units/dose; Info: for ischemic complications prophylaxis; cont. tx until pt stabilized; give w/ aspirin
DVT/PE tx (off-label)
- [200 units/kg/day SC divided qd-bid]
- Max: 18,000 units/day; Info: cont. for >5 days and overlap w/ warfarin until INR 2-3
perioperative anticoagulation bridging (off-label)
- [200 units/kg/day SC divided qd-bid]
- Start: 3 days preop; Max: 18,000 units/day; Info: for pts w/ high VTE risk who require VKA interruption; D/C 24h before surgery or invasive procedure; resume tx >24h postop and overlap w/ warfarin until therapeutic INR; refer to ACCP guidelines
renal dosing
- [DVT/PE extended tx, cancer pts]
- CrCl <30: adjust dose to anti-Xa levels 0.5-1.5 units/mL
- HD/PD: not defined, caution advised
- [all other indications]
- mild-moderate impairment: not defined; severe impairment: not defined, caution advised
- HD/PD: not defined, caution advised
hepatic dosing
- [not defined]
Peds Dosing .
- Dosage forms: INJ (pre-filled syringe): 2500 units per 0.2 mL, 5000 units per 0.2 mL, 7500 units per 0.3 mL, 10,000 units per mL, 12,500 units per 0.5 mL, 15,000 units per 0.6 mL, 18,000 units per 0.72 mL, INJ (vial): 2500 units per mL, 25,000 units per mL
DVT/PE tx
- [>35 wk gestation, <2 yo]
- Dose: individualize dose SC; Start: 150 units/kg/dose SC bid; Info: may adjust dose by 25 units/kg to target anti-Xa levels 0.5-1 units/mL; decr. daily dose by 50% if Plt 50,000-100,000; D/C if Plt <50,000
- [2-7 yo]
- Dose: individualize dose SC; Start: 125 units/kg/dose SC bid; Info: may adjust dose by 25 units/kg to target anti-Xa levels 0.5-1 units/mL; decr. daily dose by 50% if Plt 50,000-100,000; D/C if Plt <50,000
- [8-16 yo]
- Dose: individualize dose SC; Start: 100 units/kg/dose SC bid; Info: may adjust dose by 25 units/kg to target anti-Xa levels 0.5-1 units/mL; decr. daily dose by 50% if Plt 50,000-100,000; D/C if Plt <50,000
renal dosing
- [not defined]
- renal impairment: consider adult renal dosing for guidance
- HD/PD: consider adult renal dosing for guidance
hepatic dosing
- [not defined]