Dosing Flashcards
Dose of UFH for VTE treatment
IV 80 units/kg bolus, followed by continuous infusion of 18 units/kg/hour
Dose of UFH for VTE prophylaxis in medically-ill patients
SC 5000 units q8-12 hours for LOS or until fully ambulatory
Dose of UFH for VTE prophylaxis in non-ortho surgery patients
- SC 5000 units q8-12 hours with initial dose at least 2 hours prior to surgery
- May postpone until after surgery
- Continue until fully ambulatory and risk of DVT has diminished (~10 days)
Dose of UFH for VTE prophylaxis in ortho surgery patients
- SC 5000 units q8-12 hours, initial dose at least 12 hours pre-op or at least 12 hours post-op once hemostasis achieved
- Continue for 10-14 days (max 35 days)
- If extended duration needed, consider changing to an OAC or alternative SC agent
Dose of UFH for PCI with no previous use of antithrombotic use
- IV 2000-5000 units (max 50-70 units/kg) to achieve ACT of 250-300 s
- Repeat bolus (max 10,000 units ) PRN to maintain ACT throughout
Dose of UFH for PCI with previous use of GPIIb/IIIa inhibitor
- IV 2000-5000 units (max 50-70 units/kg) to achieve ACT of 250-300 s
- Repeat bolus (max 7000 units ) PRN to maintain ACT throughout
Dose of UFH for PCI with previous use of UFH/LMWH
Always check ACT prior to administration, if > 2000 s, no bolus
Dose of enoxaparin for VTE treatment
SC 1 mg/kg q12 hours (preferred)
SC 1.5 mg/kg QD
If CrCl < 30: 1 mg/kg QD
Dose of enoxaparin for VTE prophylaxis in medically-ill and surgery patients
SC 40 mg QD until ambulatory
Dose of enoxaparin for THR / HFS
SC 40 mg QD or 30 mg BD for 10-14 days, up to 35 days
Dose of enoxaparin for VTE prophylaxis in patients with renal impairment
CrCl 30-50: SC 30 mg q12 hours, consider checking anti-factor Xa
CrCl <30: SC 20 or 30 mg QD
Dose of enoxaparin for PCI usually
Last SC LMWH 8-12 hour before: IV 0.3 mg/kg bolus
Last SC LMWH >12 hour before: use UFH
Last SC LMWH < 8 hour before: no need for further LMWH
Dose of enoxaparin for PCI in MI patients with previous thrombolytic
- Start between 15 min before and 30 min after PCI
- If < 75 y: IV bolus 30 mg followed by 1 mg/kg q12 hours
- If at least 75 y: omit bolus, followed by 0.75mg/kg q12 hours
- Treat for 48 hours, up to 8 days or until revascularisation
Dose of bivalirudin for VTE treatment
IV 015-0.2 mg/kg/hour
Adjust to aPTT 1.5-2.5x of the baseline value
Dose of bivalirudin for PCI
- IV 0.75 mg/kg bolus, followed by IV infusion 1.75 mg/kg/hour for up to 4 hours after PCI
Dose of fondaparinux in VTE treatment
< 50 kg: SC 5 mg QD
50-100 kg: SC 7.5 mg QD
>100 mg: SC 10 mg QD
Dose of fondaparinux in PCI
SC 2.5 mg/day
Dose of dabigatran for VTE treatment
- Parenteral anticoagulant for at least 5 days
- 150 mg BD
CrCl < 50 + concomitant PGP inhibitor: Avoid dabigatran
Dose of dabigatran for VTE prophylaxis
- Ensure hemostasis achieved
- Start within 1-4 hours post-op
- 220 mg/day x 10 days (TKR) or 28-35 days (THR)
CrCL 30-50: use with caution, 150 mg OM for same duration as above
Dose of rivaroxaban for VTE treatment
15 mg BD x 3 weeks
20 mg/day for up to 6 months
10 mg OM for extended (or 15 mg OM by EMA)
CrCl <30: avoid
Dose of rivaroxaban for VTE prophylaxis
- Ensure hemostasis achieved
- Start 6-10 hours post-op
- 10 mg/day x 2 weeks (TKR) or 5 weeks (THR)
For medically ill: 10 mg/day for up to 31-39 days
Dose of apixaban for VTE treatment
10 mg BD x 7 days
5 mg BD for up to 6 months
2.5 mg BD (if extended)
CrCL 15-29: use with caution
HD: Avoid
Dose of apixaban for VTE prophylaxis
- Ensure hemostasis achieved
- 12-24 hours post-op
- 2.5 mg BD x 10-14 days (TKR) or 32-35 days (THR)
Dose of edoxaban for VTE treatment
- Initial parenteral anticoagulant for at leats 5 days
- 60 mg/day
CrCL 30-50 OR body weight 60 or below: 30 mg
CrCL > 95: avoid
