heparin

Adult Dosing .

Dosage forms:  INJ

thromboembolism prophylaxis

[5000 units SC q8-12h]

Info: D/C if Plt <100,000

thromboembolism tx

[18 units/kg/h IV]

Start: 80 units/kg/dose IV x1; Alt: 5000 units IV x1, then 1000 units/h IV; 333 units/kg/dose SC x1, then 250 units/kg/dose SC q12h; Info: adjust dose to target aPTT or anti-Xa levels based on nomogram; D/C if Plt <100,000

PCI

[prior anticoagulant tx]

Dose: 2000-5000 units IV prn; Info: adjust dose to target ACT 200-250sec if planned GP IIb/IIIa inhibitor, otherwise target ACT 250-350sec; D/C if Plt <100,000

[no prior anticoagulant tx]

Dose: 50-70 units/kg/dose IV x1; Info: adjust dose to target ACT 200-250sec if planned GP IIb/IIIa inhibitor, otherwise give 70-100 units/kg/dose IV x1 to target ACT 250-350sec; D/C if Plt <100,000

acute coronary syndrome, adjunct tx

[STEMI]

Dose: 12 units/kg/h IV; Start: 60 units/kg/dose up to 4000 units IV x1; Max: 1000 units/h; Info: use w/ thrombolytic; adjust dose to target aPTT or anti-Xa levels based on nomogram; D/C if Plt <100,000

[NSTEMI]

Dose: 12 units/kg/h IV x48h or until PCI; Start: 60 units/kg/dose up to 4000 units IV x1; Max: 1000 units/h; Info: adjust dose to target aPTT or anti-Xa levels based on nomogram; D/C if Plt <100,000

anticoagulation, cardiopulmonary bypass

[300-400 units/kg/dose IV x1]

Info: adjust dose to target ACT 400-480sec; D/C if Plt <100,000

VTE prophylaxis, cardioversion (off-label)

[70 units/kg/dose IV x1, then 15 units/kg/h IV]

Start: ASAP before or immediately after cardioversion; Info: for pts w/ afib/flutter duration <48h and CHA2DS2-VASc score >2, or afib/flutter duration >48h (or unknown) w/ hemodynamic instability; adjust dose to target aPTT or anti-Xa levels based on nomogram; D/C if Plt <100,000; continue tx w/ oral anticoagulant for at least 4wk after procedure; refer to ACC/AHA/HRS guidelines

perioperative anticoagulation bridging (off-label)

[12-18 units/kg/h IV]

Start: 3 days preop; Info: for pts w/ high VTE risk who require VKA interruption; adjust dose to target aPTT or anti-Xa levels based on nomogram; D/C 4-6h before surgery or invasive procedure; resume tx >24h postop and overlap w/ warfarin until therapeutic INR; D/C if Plt <100,000; refer to ACCP guidelines

renal dosing

[no adjustment]

renal impairment: no adjustment

HD/PD: no adjustment; no supplement

hepatic dosing

[not defined]

Peds Dosing .

Dosage forms:  INJ

venous thromboembolism prophylaxis

[100 units/kg/dose IV x1]

Info: for cardiac catherization; further doses may be required in prolonged procedures; D/C if Plt <100,000

venous thromboembolism tx

[<1 yo]

Dose: 28 units/kg/h IV; Start: 75 units/kg/dose IV x1; Info: adjust dose to target anti-Xa levels 0.35-0.7 units/mL; decr. or withhold bolus dose if bleeding risk; D/C if Plt <100,000

[>1 yo]

Dose: 20 units/kg/h IV; Start: 75 units/kg/dose IV x1; Info: adjust dose to target anti-Xa levels 0.35-0.7 units/mL; decr. or withhold bolus dose if bleeding risk; D/C if Plt <100,000

renal dosing

[no adjustment]

renal impairment: no adjustment

HD/PD: no adjustment; no supplement

hepatic dosing

[not defined]