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2.8 Anticoagulants

2.8.1 Parenteral anticoagulants

Treatment
Enoxaparin (prophylaxis/treatment of DVT, PE and acute coronary syndromes). Click here for guidance on prescribing enoxaparin: 

Please note: Short courses (up to 6 weeks) of LMWH are provided by the acute hospital trusts

Heparin sodium IV Infusion (anticoagulation for AF prior to warfarinisation, alternative treatment for DVTs and PEs)
Danaparoid (first-line treatment in heparin-induced thrombocytopenia (HIT))
Epoprostenol Infusion (used as a second line anticoagulant for patients undergoing dialysis who become thrombocytopenic with IV heparin)
Fondaparinux injection (ACS only) - link to guideline
Bivalirudin for high risk patients with STEMI undergoing percutaneous coronary intervention (in combination with aspirin and clopidogrel). See NICE TA 230.
Citralok 4% central venous catheter lock in patients intolerant of heparin (e.g HIT)
Taurolock - for maintaining haemodialysis central venous catheters in patients with HIT or gentamicin allergy (RENAL USE ONLY). See Antibiotic line locks for CVCs in adults on haemodialysis
Argatroban injection (HIT in renal pts only)

Notes:

1. For the treatment of DVT & PE, enoxaparin is given once daily as a subcutaneous injection at a dose of 1.5mg/kg.

2. For the treatment of ACS, the fondaparinux dose is 2.5mg stat, with subsequent doses of 2.5mg given ONCE daily on the following days at 6 pm, for a recommended total of 4 doses (unless otherwise indicated by a cardiologist).

Thromboprophylaxis

Enoxaparin 40mg daily by subcutaneous injection for high risk patients;

Enoxaparin 20mg daily by subcutaneous injection for minimal to moderate risk patients.

Reduced dosing of enoxaparin 20mg daily in patients with severe renal impairment (creatinine clearance < 30 mL/minute), due to decreased clearance of the drug and a resulting increase in exposure.

Patients with mild or moderate renal impairment require no specific dose adjustments

For dosing in patients at extremes of body weight:
Body weight(kg)      Enoxaparin Dose
< 50                           20 mg once daily
50 – 100                   40 mg once daily
>100-150                 60 mg once daily
>150                         80 mg once daily

For patients post-op with epidural device in place: 40mg once daily

Please note, these dose recommendations have been incorporated into the new thromboprophylaxis pathways for adult medical, and surgical patients.  VTE prophylaxis:

Medical

Surgical

Orthopaedics 

Heparin calcium (Calciparine®) by sub-cutaneous injectionLepirudin (for use in heparin-induced thrombocytopenia)

Danaparoid (for use in heparin-induced thrombocytopenia - available on a named patient basis).

 

2.8.2 Oral anticoagulants

Click here for Atrial Fibrillation guidelines.

Anticoagulant Guidelines / Interactions
Click here for list of common anticoagulant drug interactions
Warfarin tablets

It is district policy that patients in Southern Derbyshire are only issued with one strength of warfarin tablet in order to prevent confusion. The 1mg tablet is listed for this purpose.

Rivaroxaban tablets
Dabigatran etexilate capsules
  • for stroke prevention in AF - see NICE TA 249

  • for thromboprophylaxis after elective hip/knee surgery - see NICE TA 157
  • for the treatment and secondary prevention of DVT/PE – see NICE TA327
Apixaban tablets
  • for thromboprophylaxis after elective hip/knee replacement - see NICE TA 245

  • for prevention of stroke and systemic embolism in AF - see NICE TA 275

  • for treatment / secondary prevention of  DVT / PE – see NICE TA341

Edoxaban tablets
  • for treatment / secondary prevention of DVT / PE – see NICE TA354

  • for prevention of stroke and systemic embolism in AF – see NICE TA355

  

1. Warfarin has very rarely been associated with calciphylaxis, a serious condition causing vascular calcification and skin necrosis. Patients should be advised to consult their doctor if they develop a painful skin rash (see DSU July 2016). 

2. Rivaroxaban is the preferred NOAC formulary choice.

3. All the NOACs have been associated with serious haemorrhage. The MHRA has reviewed it's contraindications and warnings to include lesions or conditions where there is a significant risk of major bleeding, including concomitant treatment with other anticoagulant agents / NSAIDs or anti-platelets (these are listed in the Drug Safety Update for October 2013). In addition, renal function should be assessed in all patients before starting a NOAC and periodically throughout treatment. Dabigatran is contraindicated with creatinine clearance <30ml/ml; apixaban and rivaroxaban are contraindicated with creatinine clearance <15ml/ml).See also the local clinical guidelines on the use of new oral anticoagulants (NOACs) above.

4. Dabigatran is contraindicated in patients with prosthetic heart valves because of the risk of thromboembolic and bleeding events - see the Drug Safety Update for March 2013.

5. The NICE guideline on MI: cardiac rehabilitation and prevention of further MI advises against using a NOAC in combination with dual antiplatelet therapy in people who have had an MI. It recommends considering using warfarin and discontinuing treatment with a NOAC in such people, unless there is a specific clinical indication to continue it. This relates to people who have an indication for anticoagulation, such as atrial fibrillation which may or may not be related to their MI. The full guideline explains that the recommendation arises from the limited evidence for the use of NOACs in this context, and the likely increased risk of bleeding.

 The above NICE TAs should be read in the context of relevant NICE clinical guidelines:

 

2.8.3 Protamine sulphate injection

Used to reverse the effects of heparin (and to a degree LMWH)

See protamine SPC for dosing and administration advice.

 

 

 

 For the link to the BNF: 2.8 Anticoagulants and protamine