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UFH & LMWH
Clinical kinetics
| Question | Answer |
|---|---|
| which JUST inhibits Xa | Low molecular weight heparin (Enoxaparin) |
| MOA from LMWH | Antithrombin binds to factor Xa |
| LMWH: VTE (DVT or PE) Initial dosing | 1mg/kg SQ q12 hours OR 1.5mg/kg SQ q24hours |
| LMWH: Unstable angina NSTEMI initial dosing | 1mg/kg SQ q12 hours |
| LMWH: STEMI initial dosing | IV bolus of 30mg + 1mg/kg SQ q12 hours |
| bridging for LMWH initial dosing | 1mg/kg SQ q12 hours |
| LMWH: renal dose adjustment (Crcl <30) | 1mg/kg SQ q24 hours |
| dosing for enoxaparin (Lovenox) | 30mg/0.3mL, 40mg/0.4mL, 60mg/0.6mL, 80mg/0.8mL, 100mg/mL, 120mg/0.8mL, 150mg/mL |
| Distribution for LMWH | not highly protein bound |
| Renal adjustments for LMWH | Not recommended in dialysis |
| LMWH monitoring safety | Baseline: CBC (Hgb, HCT, platelets), SCr. Routine Monitoring, CBC and SCr periodically: Inpatient: daily or every other day, Outpatient: Every 4-6 months or as clinically indicated (s/sx bleeding), Platelet monitoring for HIT (s/sx bleeding |
| LMWH monitoring when should we obtain anti Xa levels | in special populations |
| what are the special populations in LMWH | renal crcl<30, extreme weight >190kg or <50kg, pediatrics, liver disease, pregnancy |
| What are the target peak levels form LMWH | 1mg/kg BID dosing: 0.5-1.0 units/mL OR 1.5mg/kg daily dosing: 1.0-2.0 units/mL |
| when do we draw peak levels for LMWH | Draw level 4 hours after 2nd or 3rd dose |
| LMWH reversal (time escaped < 8 hours) | Dose: 1mg neutralizes ~ 1mg of enoxaparin • Calculate enoxaparin dose administered over last 8 hours • Do NOT exceed 50 mg can promote bleeding |
| LMWH are monitored with | Anti Xa |
| Anti-Xa Monitoring measures/ detects | medications that inhibit factor Xa |
| Anti-Xa Monitoring therapeutic level is | 0.3 – 0.7 unit/mL *Blood samples for monitoring must be processed within 1 hour |
| Anti-Xa Monitoring benefits | More rapid attainment of target values, Fewer rate adjustments, Fewer extraneous factors impacting levels |
| Anti-Xa Monitoring disadvantage | Expensive, Not available in every hospital, Samples must be processed within 1 hour of collection, Unreliable if patient is transitioned from another agent with Xa effects, Anti-Xa may be falsely elevated up to 96 hours after the last dose of a DOAC |
| which inhibits thrombin (IIa) and Xa | Unfractionated Heparin (UFH) |
| MOA for UFH | Antithrombin binds to Factor Xa blocking its function. UFH can also block the function of Thrombin (aka Factor IIa) |
| UFH: Acute coronary syndrome (ACS) Bolus dose | Bolus: 60 units/kg Max: 5,000 units |
| UFH: Acute coronary syndrome (ACS) initial maintenance dosing | Maintenance: 12 units/kg/hr. Max initial rate: 1,000 units/hr |
| UFH: VTE (DVT or PE) Bolus dose | Bolus: 80 units/kg Max: 10,000 units |
| UFH: VTE (DVT or PE) initial maintenance dosing | Maintenance: 18 units/kg/hr Max initial rate: 2,000 units/hr |
| UFH: Atrial Fibrillation bolus dose | Bolus: 60-80 units/kg Max: 5,000 units |
| UFH: Atrial Fibrillation initial maintenance dosing | Maintenance: 12-18 units/kg/hour Max initial rate: 1,000 units/hr |
| UFH Bridging bolus | not indicated |
| UFH Bridging initial maintenance dosing | Maintenance: 12-18 units/kg/hr |
| UFH omit bolus when | high bleeding risk |
| UFH baseline monitoring | Hemoglobin, Hematocrit, Platelets |
| UFH monitor safety | CBC daily or every other day. Monitor for signs of HIT: • Platelet decrease by 50% OR decrease to <150 K/µL • Signs/symptoms of bleeding • Hemoglobin, Hematocrit, Platelets |
| UFH monitor Assay | Obtain heparin assay 6 hours after heparin initiation, Obtain heparin assay every 6 hours after every dose change until 2 consecutive therapeutic levels are reached, Obtain heparin assay once daily after 2 consecutive therapeutic levels have been reached |
| aPTT Monitoring for UFH therapeutic effects | ~60 to 85 seconds |
| UFH Reversal (Time elapsed: Immediate) | Dose: 1mg neutralizes ~ 100 units of heparin • Calculate heparin dose administered over last 3 hours • Do NOT exceed 50 mg can promote bleeding |
| UFH PK distribution | is highly protein bound |
| UFH PK renally dose adjustment | no renal adjustments |
| UFH is monitored with | aPTT and Anti Xa |
| aPTT benefits | Inexpensive, Time from sample collection to sample testing is more forgiving |
| aPTT disadvantages | Several factors besides the anticoagulant can impact aPTT such as liver failure and the presence of lupus anticoagulant, Must be calibrated at each institution for accurate measurements |
| aPTT Measures | how long it takes for a clot to form and evaluates coagulation factors of the intrinsic and common pathways |
Created by:
arcervantes
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