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2.8.1 Parenteral anticoagulants

2.8.1 Parenteral anticoagulants

2.8.1 Parenteral anticoagulants

      Unfractionated heparin

           RED          Heparin sodium injection 1,000 units/mL

           Intravenous heparin flushes are widely used to keep peripheral and indwelling lines patent. There are risks in their use due
           to poor practice such as not being formally prescribing or part of a patient group direction. Wrong products and strengths
           have been selected. There is no evidence that heparin flushes have any advantage over normal saline for keeping peripheral
           lines patent so the latter should be used. For more complex devices such as central venous or arterial catheters, the 
           evidence is less clear. More specific policies may be required depending on the individual devices in use. All flush solutions
           should only be administered following a prescription or patient group direction.
           AMBER     Heparin sodium injection 10 units/mL (flush only)
           Low molecular weight heparins (LMWH) and fondaparinux
           There are a number of LMWHs licensed for both prevention and treatment of DVT/PE in the UK. The low molecular weight
           heparin (LMWH) for prophylaxis and treatment of venous thromboembolism used in East Lancashire hospitals for surgical,
           medical and obstetric patients is tinzaparin. 
           Prophylaxis of venous thromboembolism 
           RED          Tinzaparin injection 
                            2500 units(0.25mL), 3500 units(0.35mL), 4500 units(0.45mL)  Pre-filled syringes    
           N.B: Care when prescribing/selecting strength of syringes - Different strengths available. 
           Not for GP prescribing. Whole course supplied by hospital. Nursing staff may still administer with written authorisation.
           Prescribers should ensure adequate supplies for patients, as they will not be able to get additional supplies from their GP.
           Treatment of pulmonary embolism and venous thrombosis.
           AMBER    Tinzaparin  injection 
                             8,000 units(0.4mL),10,000 units(0.5mL), 12,000 units(0.6mL), 
                            14,000 units(0.7mL), 16,000 units(0.8mL), 18,000 units(0.9mL), - pre-filled syringes, and 
                            40,000 units in 2mL multidose vial
           N.B: Care when prescribing/selecting strength of syringes - Different strengths available.    
           For initiation by or on the recommendation of a specialist, and continuation by a primary care prescriber with the relevant
           competencies to do so. Nursing staff may still administer with written authorisation.
           For full guidance including Indications and monitoring, see..  
           Best Practice Guidance: Use of Low Molecular Weight Heparins (LMWH) in Primary Care - latest version (4) 
           Treatment of DVT and PE for hospitalised patients   
           Prescriptions must include the indication when written on the inpatient prescription chart, i.e. Tinzaparin treatment. 
           In addition the dose prescribed and the volume to be administered must also be clearly stated, and the patients weight  
           should also be stated on the prescription.
           Thromboprophylaxis for medical & surgical inpatients
         EVERY hospitalised patient should have a documented, mandatory, VTE risk assessment on admission to identify any 
           individual risk factors  (in addition to any proposed surgery) that are known to increase the risk of developing venous 
           Prescriptions must include the indication when written on the inpatient prescription chart, i.e. Tinzaparin prophylaxis.  In  
           addition the dose prescribed and the volume to be administered must also be clearly stated.
           N.B: Care when prescribing/selecting strength of syringes - Different strengths available. 
           Monitoring Requirements for LMWHs (does not include fondaparinux)
  • All patients who are to receive LMWH should have a platelet count checked on the day of starting  treatment.
  • Patients exposed to LMWH (or heparin) in the last 100 days should have another platelet count check 24 hours after  starting LMWH.
  • If the platelet count falls by 50% or more or the patient develops new thrombosis or skin allergy at injection sites between day 4 and 14 consider a diagnosis of Heparin induced thrombocytopenia and discuss with a haematologist urgently.
  • There is NO need to monitor the anticoagulant activity of tinzaparin. eg INR or APTT
          Bivalirudin is a hirudin analogue, thrombin inhibitor which is licensed for acute coronary syndromes.
          NICE guidance TA230 advises on its use in MI with persistent ST-segment elevation.
          RED           Bivalirudin injection (Angiox®) 250mgs
          A prostacyclin that can be given during renal dialysis either alone or with heparin, and it is also licensed for the treatment of 
          primary  pulmonary hypertension resistant to other treatments.  It is also used in Raynaud’s syndrome (unlicensed). 
          RED           Epoprostenol injection 500micrograms 
         A synthetic pentasaccharide that inhibits activated Factor X 
         RED           Fondaparinux injection 2.5mg/0.5mL 
         Treatment of acute coronary syndrome (ACS).  
         This includes SUSPECTED acute NSTEMI, Troponin Positive ACS and STEMI in conjunction with thrombolysis. 
         Fondaparinux is administered as a fixed dose, 2.5mg/0.5mL once daily injection with no requirement to weigh the patient.  
         There is no need to monitor platelets.
         Note: Fondaparinux provides a prophylactic level of anticoagulation and therefore is NOT suitable for indications where a therapeutic
         level of anticoagulation is required e.g. mechanical prosthetic valve, AF with high risk of cardiac thromboembolism, venous
         thromboembolism.  Use full dose tinzaparin in these cases.

         RED         Enoxaparin solution for injection
         An option in the treatment of acute coronary syndrome when fondaparinux cannot be used
         For the treatment of unstable angina and Non ST Elevation MI (except those patients receiving emergency   
         (<120minutes) PCI*: 
         Dose:    2.5mg ONCE DAILY
         Mode of Administration:  Subcutaneous
         N.B. This should be discontinued for patients with unstable angina if their Troponin comes back negative.
         For the treatment of ST Elevation MI in patients receiving thrombolysis (fondaparinux should be given in combination
         with either streptokinase or tenecteplase):   
         Dose:    2.5mg ONCE DAILY
         Mode of Administration: The first dose should be administered Intravenously and subsequent doses by subcutaneous 
         Do not expel the air bubble prior to administration.
         *For intravenous administration the injection should be given through an intravenous bung into a cannula followed by a flush 
           with 5mL Sodium Chloride 0.9%.
         Length of treatment: For 48hrs after the last chest pain, up to 8 days or until hospital discharge. Patients undergoing  
         exercise testing should be pain free and off fondaparinux for 24 hours – withhold fondaparinux on day of discharge.
         Renal Impairment: Do not use if eGFR < 20 – Unfractionated Heparin should be used as per local protocols. No dose 
         reduction is needed if eGFR > 20

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