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An#coagulant  Choices  in  Renal  

Impairment

 

Karen  Shalansky,  Pharm.D.  

Pharmacotherapeu#c  Specialist,  Nephrology   Vancouver  General  Hospital  

Clinical  Professor  

Faculty  of  Pharmaceu#cal  Sciences,  UBC  

karen.shalansky@vch.ca  

April  18,  2012  

(2)

Disclosures

 

I have no known or real conflicts

of interest to declare

 

(3)

Outline  

Review  mechanisms  of  ac0on  of  an0coagulants  

Compare  the  new  oral  an0coagulants    

• dabigatran,  rivaroxaban,  apixaban  

Discuss  an0coagulant  op0ons  in  renal  impairment  

Focus  on  LMWH  use  in  renal  impairment  

Role  of  an0-­‐Xa  monitoring  

cases  with  clinical  use  of  LMWH  in  dialysis  

• Long-­‐term  0nzaparin  and  an0-­‐Xa  levels  

• Triple  an0coagulant  therapy    

• Bridge  Therapy    

(4)

Fibrin  Clot   XII   VII   VIII   IX   XI  

II  

V

X

I

 

Unfrac#onated   Heparin   Warfarin   Low   Molecular   Weight   Heparin  

An#coagulant  Sites  of  Ac#on  

Direct  Thrombin  (IIa)   Inhibitors  -­‐  dabigatran,   argatroban  

Factor  Xa  Inhibitors  –  

rivaroxaban,  apixaban,   fondaparinux    

(5)

Dabigatran  etexilate   Rivaroxaban     Apixaban    

Target  Inhibi#on   Both  free  and  clot  bound    Factor  IIa  (Thrombin)   Factor  Xa   Factor  Xa  

Coag  Assay*   aPTT    (2-­‐3x);  Thrombin  #me  (27x)  

↑  INR  40%   Xa  inhibi0on  (68%)   ↑  aPTT  40%;  ↑  INR  40%   Xa  inhibi0on     ↑  aPTT;  ↑  INR   Oral  Bioavailabilty   6-­‐7%   60-­‐80%   50%   T  (max)   1-­‐3  h   2-­‐4  h     1-­‐3  h     Half-­‐life   14-­‐17  h   9-­‐13  h   8-­‐15  h     Metabolism  /  

Elimina#on   20%  biliary    80%  renal    

66%  renal  (36%   unchanged)    

33%  biliary    

25%  renal     75%  biliary  

Dialyzable   Yes   No  (92-­‐95%  PB)   Unlikely  (87%  PB)  

Hold  Prior  to   Surgery  

eGFR  >  50  mL/min   Minor  surgery:  1  day   Major  surgery:  3  days

 

Minor  surgery  :  1  day  

Major  surgery:  2  days   Rivaroxaban  ?  Similar  to    

CYP  Metabolism   No   30%  CYP3A4   15%  CYP3A4  

P-­‐glycoprotein  

Substrate   Yes   Yes   Yes  

Compara#ve  Features  of  New  Oral  An#coagulants  

(6)

P-­‐Glycoprotein  Drug  Interac#ons  with  NOA  

•  P-­‐glycoprotein  (P-­‐gp)  is  a  transport  protein  that  func0ons  as  an  

efflux  pump  to  prevent  absorp0on  of  certain  drugs,  including   the  new  oral  an0coagulants  

•  Inhibitors  of  P-­‐gp  –  increase  absorp0on  of  NOA  

Azole antifungals* Ritonavir* amiodarone verapamil quinidine cyclosporin tacrolimus Clarithro/Erythro* Inhibitors Rifampin** Phenytoin** Carbamazepine** Phenobarbital** Dexamethasone Doxorubicin St. Johns Wort** Inducers

(7)

New  Oral  An#coagulant  (NOA)  Trials  

Dabigatran   Rivaroxaban   Apixaban  

Orthopedic   Prophylaxis    

(Total  Hip  and  Knee   Replacement)  

ü

 

RE-­‐MOBILIZE   RE-­‐MODEL   RE-­‐NOVATE  

ü

 

RECORD  1   RECORD  2   RECORD  3   RECORD  4  

ü

 

ADVANCE  1   ADVANCE  2   ADVANCE  3  

Stroke  preven0on  in  

Atrial  Fibrilla0on   RE-­‐LY  (W)  

ü

 

ROCKET  AF  (W)  

ü

   

AVERROES  (ASA)     ARISTOTLE  (W)  

VTE  Treatment     RECOVER  REMEDY  

EINSTEIN  PE   EINSTEIN  DVT   EINSTEIN-­‐EXT  

AMPLIFY   AMPLIFY-­‐EXT  

(8)

Canadian  Dosing  Guidelines  for  NOA  

Dabigatran   Rivaroxaban     Apixaban    

       Orthopedic  Prophylaxis  (TKR  =  x  14  days;  THR  =  x  35  days)  

         >  50  mL/min   220  mg  daily     10  mg  daily   2.5  mg  BID  

       30-­‐50  mL/min   150  mg  daily     10  mg  daily    (Cau0on)   2.5  mg  BID  

     15-­‐29  mL/  min   Avoid  (black  box)   Avoid   2.5  mg  BID  (AUC    44%)  (Cau0on)  

<  15  mL/min   Avoid   Avoid   Avoid  

         Stroke  Preven#on  in  Atrial  Fibrilla#on  

         >  50  mL/min   150  mg  BID   20  mg  daily  

       30-­‐50  mL/min  

150  mg  BID    

(if    ≥  75  yrs  +  risk  factor   for  bleeding,  consider   110  mg  BID)  

15  mg  daily  

(9)

Advantages  of  New  Oral  An#coagulants  

Fixed  dosing  

Monitoring  of  an0coagulant  effect  not  

required  

(10)

Limita#ons  of  New  Oral  An#coagulants  

•  Inability  to  Measure  an0coagulant  effect  

–  Poten0al  for  increased  risk  of  stroke  or  embolism  if  poor  compliance  

–  Poten0al  for  increased  risk  of  bleed  if  reduced  renal  func0on/DI  

(Dabigatran  -­‐  260  fatal  bleeding  events  worldwide  Mar  08  to  Oct  11)  

•  Lack  of  specific  an0dote  

–  Prothrombin  complex  concentrate  (Octaplex®)  for  intracranial  hemorrhage  

(Octaplex®  –  plasma  derived,  purified  Factors  II,  VII,  IX,  X,  protein  C  and  S)  

•  Some  drug  interac0ons    

–  p-­‐glycoprotein  inhibitors/inducers  

•  Dose  adjustments  required  in  renal  dysfunc0on  

–  Should  not  be  prescribed  for  eGFR  <  30  mL/min  (BLACK  BOX  for  dabigatran)  

•  Cost  

–  Rivaroxaban  covered  for  orthopedic  prophylaxis  

(11)

An#coagulant  Op#ons  in  Renal  Failure  

Drugs  with  no  significant  renal  clearance  

–  Unfrac0onated  heparin  (UFH)  

–  Warfarin  

–  Direct  Thrombin  Inhibitors:  argatroban  

–  Direct  Factor  Xa  inhibitors:  apixaban  (avoid  <  15  mL/min)  

Drugs  with  significant  dependence  on  renal  clearance  

–  Low  molecular  weight  heparins  (LMWHs)  

–  Factor  Xa  inhibitors:  

• Indirect  -­‐  Pentasaccharide:    fondaparinux    

• Direct  –  rivaroxaban  

–  Heparinoids:  danaparoid  

(12)

Factor  Xa  Inhibitors  

Indirect  Inhibitors  

•   Fondaparinux     •   Idraparinux  

Direct  Inhibitors  

•   Rivaroxaban     •   Apixaban   •   Edoxaban     •   Betrixaban   FOND

(13)

Fondaparinux  

Regional  Approval    

Unstable  angina/non-­‐STEMI  (2.5  mg  SC  daily)  

Management  of  HIT    

• Tx  VTE:  5-­‐10  mg  SC  daily;  Prophylaxis  VTE:  2.5  mg  SC  daily  

• Easier  to  administer  vs  argatroban  (con0nuous  infusion)  

Elimina0on  

t/12  =  17-­‐21  hrs;  Elimina0on  =  77%  unchanged  urine  

Renal  Dosing  (hemodialysis)  –  case  reports  

Tx  VTE:  2.5  mg  SC  every  2  days  (monitor  an0-­‐Xa  levels    

3  h  peak  0.5-­‐1.5;  trough  <  0.5)  

• Give  dose  ater  dialysis  

(14)
(15)

2012  ACCP  Guidelines  

Appropriate  dose  of  LMWH  in  pa0ents  with  severe  

renal  insufficiency  (<  30  mL/min)  is  uncertain  

Clearance  of  the  an#-­‐Xa  effect  of  LMWH  correlates  

with  CrCl  (enoxaparin,  nadroparin,  dalteparin)  

–  Excep#on:  Tinzaparin  not  shown  to  correlate  with  CrCl  

If  severe  renal  insufficiency  and  therapeu0c  

an0coagula0on  required,  suggest  UFH  over  LMWH    

If  LMWH  is  used  in  pa0ents  with  severe  renal  

insufficiency  for  therapeu0c  an0coagula0on,  

suggest  monitor  an0-­‐Xa  levels  

(16)

Measure  in  pa0ents  with  renal  failue  (CrCl  <  30  

mL/min)  or  obesity  

Measure  peak  effect  (4  hours)  

3-­‐4  hours  ater  twice  daily  dosing  

4-­‐5  hours  ater  once  daily  dosing  

Twice  daily:  

0.6-­‐1

 units/mL  

Once  daily:  

1-­‐2

 units/mL  (Tinzaparin  0.6-­‐1.5  U/mL*)  

Trough  levels  

<  0.5

 units/mL  

An#-­‐Xa  Monitoring  

(not  an  exact  science)  

(17)

Mean  Peak  An#-­‐Xa  Levels  

(Normal  Renal  Func0on)  

(Semin Thromb Hemost 2001;27:519-22)

(18)

Heparin  and  LMWHs  

•  Pentasaccharide  

sequence  binds  to  AT   and  accelerates  its   inhibitory  ac0vity   •  Factor  Xa  –  requires  

only  pentasaccharide   •  Thrombin  –  requires  

18  saccharide  units   •  LMWHs  have  less  

ac0vity  against  

thrombin  as  longer   chain  length  required  

(19)

Clearance  of  UFH  and  LMWHs  

•  Higher  MW  chains  are  cleared  by  dose-­‐dependent  hepa0c  

mechanism  

•  Lower  MW  chains  are  cleared  by  dose-­‐independent  renal  

route  

Agent  

Average  MW  (daltons)   An0Xa:IIa  Ra0o  

UFH   15,000   1:1   Tinzaparin   6,500   1.9:1   Dalteparin   5,600   2.0  –  2.7:1   Enoxaparin   4,500   2.7  –  4.1:1   Nadroparin   4,300   3.2  –  3.7:1   (Pharmacotherapy  2001;21:218-­‐34;  Pharmacotherapy  2005;  25:881-­‐5)  

(20)

Tinzaparin  

Highest  MW  –may  be  less  dependent  upon  renal  

clearance  

Closest  an0-­‐Xa:IIa  ac0vity  compared  to  heparin

 

 

Agent  

Average  MW  

(daltons)  

An#Xa:IIa  

Ra#o  

Dose  Adjustment  

CrCl  <  30  mL/min  

Heparin   15,000   1:1   No  

Tinzaparin   6500   1.9:1   No  (short-­‐term)  

Dalteparin   5600   2.0-­‐2.7:1   ?  

Enoxaparin   4500   2.7-­‐4.1:1   Yes  (50%  -­‐  per  CPS)   Nadroparin   4300   3.2-­‐3.7:1   Yes  (no  guidelines)  

(21)

Tinzaparin  Full  Dose    

(175  units/kg/day)  

Trial   Popula#on   Dura#on   Outcome  

Drug  Safety  

2002:25:725-­‐33   200  elderly  VTEpts  ~25%  Cr  Cl  20-­‐35   mL/min  

Up  to  30  d  

(mean  19  d)   88%  peaks  <  1.5  U/mL                  (Day  1,  qweek)   -­‐  No  correla0on  to  CrCl   Thromb   Haemost   2000;84:  800-­‐4     30  elderly  VTE  pts   ~25%  CrCl  20-­‐29   mL/min  

10  days   All  peaks    <  1.1  U/mL                   (Days  1,  2,  7,  10)  

-­‐  No  correla0on  to  CrCl   Blood  2006;   108:884   (abstract)     78  pts  with  VTE   and  varying  CrCl   including  HD  

5-­‐7  days   94%  troughs  <  0.5  U/mL       (Days  3,  5,  7)  

-­‐No  correla0on  to  CrCl   Thromb  Res   2011;128:27-­‐34   (IRIS)   MC,  OL,  R  cf  UFH     539  elderly  with   DVT  and  CKD     (25%  pts  with     CrCl<  30  mL/min)   5-­‐10  days,   then   warfarin    (f/ u  =  90  d)  

-­‐ Study  stopped  early  due  to            

↑  mortality  in  Tinza  arm  at  day  

28  (11.9%  vs  6.3%,  p=0.035)           -­‐  CA,  sepsis  in  pts  ≥  90  yrs                  -­‐  

(22)

Enoxaparin  Dose  Adjustment  

Linear  correla0on  between  an0-­‐Xa  levels  and  CrCl  

–  Prolonged  t1/2  (2.94  vs  5.12  hrs  CrCl  5-­‐21  mL/min)  

CPS  dose  adjustment  for  CrCl  <  30  mL/min  

–  Treatment:  1  mg/kg  SC  Q24H    

–  Prophylaxis:  30  mg  SC  Q24H  

Poten0ally  low  peak  and  trough  levels  (up  to  26%)  

(Pharmacother  2007;27:1347;  Thromb  Res  2005;116;41)  

Pharmacokine0c  trials  

–  Treatment:    0.5-­‐0.75  mg/kg  Q12H  (Am  Heart  J  2004;148:582)  

(23)

Case  1.  Long-­‐Term  Tinzaparin

 

A  case  of  Calciphylaxis  

and  Atrial  Fibrilla#on  

(24)

Case  1.  Calciphylaxis  and  A  Fib  

79  yo  female,  75  kg  admiyed  with  calciphylaxis  

&  atrial  fibrilla0on  

 D/C  warfarin,  daily  HD  (5/7),  hyperbaric  unit,  

sodium  thiosulphate,  lanthanum  

 Started  on  0nzaparin  14,000  units  SC  daily  

 (75  kg  x  175  units/kg  =  13,  125  units)  

 

Peak  An#-­‐Xa  levels  (6h):  

• Day  3  =  0.85  units/mL  

• Day  16  =  0.88  units/mL  

• Day  37  =  0.78  units/mL  

(25)

Case  2.  Long-­‐Term  Tinzaparin  and  

Triple  An#coagulant  Therapy

 

A  case  of  An#-­‐phospholipid  

syndrome  and  MI  

(26)

Case  2:  73  yo  female,  80kg  on  HD  

Date   Event   Tinzaparin  Dose  (SC)    

Oct-­‐06  to  

Aug-­‐07   Start  HD   14,000  U  (Aug  23/07  peak  an0-­‐Xa  level  =  1.03  U/mL)                                            →  10,000  U  →  7000  U  daily                                   Aug-­‐09   Seizure  (admission)   7000  units  daily                                                                                                

+  Levateracetam  (Keppra®)  

Aug-­‐09   Pneumonia-­‐ICU   NSTEMI  x  2  

7000  units  SC  daily      

+  ASA  81mg  PO  daily                                                                               +  Clopidogrel  75  mg  PO  daily  

Dec-­‐09   Let  upper  arm  

hematoma   ASA  +  Plavix  held;  Discharged  Jan-­‐10  to      RN  home  on  triple  therapy  above   Feb-­‐10   Right  upper  arm  

hematoma  (readmit);   Heme  consult                  

D/C  Tinzaparin  and  Clopidogrel  

ASA  81mg  daily                                                                                                   +  Heparin  5000  units  SC  BID  

Sept-­‐10   Humerus  #  -­‐  fall   Deceased  (?PE  vs  sudden  cardiac  death)  

PMH:  An0phospholipid  an0body  syndrome  (DVT/PE  2000,  IVC  filter,   warfarin  failure,  a  fib)  →  Lifelong  0nzaparin  

(27)

Bleed  Risk  from  Single,  Dual,  or  Triple  

Therapy  in  Pa#ents  with  A  Fib

 

Variable   RR  (95%  CI)  non-­‐ fatal  bleed   Warfarin   1  (reference)   Crude  Rate  =  3.6%   Aspirin   0.84  (0.8-­‐0.89)   Clopidogrel   0.94  (0.76-­‐1.16)   ASA  +C   1.64  (1.33-­‐2.03)   W+ASA   1.77  (1.66-­‐1.90)   W+C   3.16  (2.48-­‐4.03)   W+C+ASA   3.93  (3.05-­‐5.05)  

(Arch  Int  Med  2010;170:1433-­‐41)  

•   Na0onwide  Danish  registry  of  

82,854  pa0ents  with  atrial  fib   discharged  on  warfarin,  ASA,  or   clopidogrel  (Jan  97-­‐Dec  06)  

 

•   Analyzed  risk  hospitaliza0on  or  

death  due  to  bleeding  

 

•   12,191  (10.3%)  had  non-­‐fatal  

(28)

Major  Bleeding  in  HD  Pa#ents  

•  Retrospec0ve  review  of  255  pts  from  Jan  2002-­‐Jan  2004              

(1028  person  years  of  exposure)  

•  25/26  major  bleeds  were  upper  or  lower  GI  bleed;  1  =  CNS  

Treatment   #  pts   Major  

Bleed   %  Major  Bleeds   Hazard  Model  for  Time  to  First  Bleed  (95%  CI)  

None   178   4   0.8%   Reference   Warfarin   89   15   3.1%   3.9  (1.05-­‐14.6)   ASA   107   12   4.4%   5.8  (1.9-­‐18.0)   ASA  +   Warfarin   50   5   6.3%   8.2  (2.2-­‐30.7)     Total   255   26   (CJASN  2008;3:105-­‐110)  

(29)

Cases  3  &  4  Bridge  Therapy

 

(30)

Peri-­‐opera#ve  Risk  Stra#fica#on  

   (Chest  2012;141:326s-­‐350s)  

Thrombosis  

Risk   Mechanical  Heart  Valve   Atrial  Fibrilla#on   VTE   Bridge    

HIGH   • Mitral  Valve  

• Older  aor0c  

valve  (0l0ng  disc)   • Recent  (<  6  mo)   stroke  or  TIA  

• CHADS2  5-­‐6   • Recent  (<  3   mo)  stroke  or   TIA   • Rheuma0c   valvular  HD   •   VTE  <  3  mo   • Severe   thrombophilia   Yes  (2C)  

MODERATE   • Bileaflet  aor0c  

valve  +  one  of:             a  fib,  stroke,  TIA,   HT,  DM,  CHF,  >  75     • CHADS2  3-­‐4     • VTE  3-­‐12  mo   • Recurrent  VTE   • Ac0ve  cancer  

Full  dose  or   Prophylac0c   dose  or                     No  bridge    

LOW   • Bileaflet  aor0c  

valve  &  no  risk   factors  for  stroke  

• CHADS2  0-­‐2   • VTE  >  12  mos   and  no  other   risk  factors  

(31)

How  to  Bridge  with  LMWH    

(Circula#on  2004;110:1658-­‐63;  Chest  2012;141:326s-­‐350s)  

Day    

 -­‐  5   Day      -­‐  3   Day      -­‐  1   Day        0   +1  to  +3    Day    

Full dose OD or BID or prophylactic dose OD

No dose within 24 h (or ½ dose in am); INR >1.5 Vit K 1mg po Restart depends on adequate hemostasis Stop   Warf   Stop   LMWH   am  /  pm   Start   LMWH   Start   Warf   12-­‐24h   post-­‐sx   Start   LMWH   am  /  pm   Stop  LMWH   when  INR   therapeu#c  

(32)

Temporary  Discon#nua#on  of  Warfarin:  

INR  Decay  with  Target  Range  2-­‐3  

Mean   INR  1.6   Mean   INR  2.6   Mean   INR  1.1   Hours      20    40      60      80      100      120      140      160      180   Age  >  55  yrs   Age  ≤  55  yrs   INR   Hours   Mean   INR  1.6   Mean   INR  2.6   Mean   INR  1.1      20    40      60      80      120      140      160      180   1 2 3 4 0  

•   N=  22  pa0ents;  serial  INRs  done  at  2.7  and  4.7  days  ater  D/C                                

(33)

Case  3:  72  yo,  91  kg  male  

Recent  bilateral  PE  July  4/11;  Hx  of  PE  and  DVT  x  2  

Pt  had  been  off  warfarin  AMA  prior  to  recent  event  

Requires  fistuloplasty  July  19/11  

Date Day Action

July 14 Day - 5 Stop Warfarin (INR = 2.7)

July 15-17 Day - 4 to - 2

(low dose ID heparin)

Start Tinzaparin 14,000 units qpm (175 units x 91kg = 15,925 units)

July 18 Day - 1 No Tinzaparin; INR = 1.0

July 19 Day 0 (if okay by

vascular)

Restart Warfarin in evening Restart Tinzaparin in evening

July 27 Day + 8 (end of 10 day

Pharmacare coverage)

(34)

Case  4:  Accidental  Overdose

 

 

Date Event Tinzaparin Dose

Aug 6 Discharged INR = 1.2 10,000 units daily

Aug 7-9 Patient error with dose; was

dispensed 3 x 20,000 unit/2 mL vial (instead of 10,000 unit syringe)

20,000 units daily x 3

Aug 10 Ran out of Tinzaparin None

Aug 11 INR = 1.3; error discovered;

Anti-Xa level ordered (43 h post)

5000 units

 74  yo,  58  kg  male  with  PE  July  27/10;    

 Hx  of  pulmonary  fibrosis  

Aug 12 Anti-Xa Level = 0.26 units/mL 10,000 units

(35)

Case  5.  LMWH  Prophylaxis

 

 

A  paraplegic  pa0ent  

 

(36)

Dalteparin  Prophylaxis  Trial:

 

DIRECT  

(Arch  Intern  Med  2008;168:1805-­‐12)

 

138  ICU  pa0ents,  CrCl  <  30mL/min  (mean  18.9mL/min)  

–  9.4%  on  dialysis  

Dalteparin  5000  U  SC  daily  <  30  days  (median  7  days;  

IQR  4-­‐12  days)      

Trough  an0-­‐Xa  levels  on  days  3,  10,  17

 

 

Results:  

All  trough  an0-­‐Xa  levels  <  0.4  units/mL    

No  evidence  of  accumula0on  

DVT  =  5.1%  

Major  bleeding  =  7.2%  

(37)

VTE  Prophylaxis  Guidelines:  VCH/PHC  

Dalteparin  5000  units  SC  daily  (eGFR  >  10  mL/min)  

–  If  pa0ent  has  eGFR  10-­‐30  mL/min  and  therapy  to  extend  

beyond  10  days,  consider  switch  to  heparin  Q12H  

Heparin  5000  units  SC  Q12h  (eGFR  <  10  mL/min)  

   

Weight Range Dalteparin

(eGFR > 10mL/min )

Heparin (eGFR < 10 mL/min)

40 kg or less 2500 units SC daily 2500 units SC Q12H

41 kg to BMI 40 kg/m2 5000 units SC daily 5000 units SC Q12H

(38)

Case  5:  Dalteparin  Prophylaxis  

 

Date Event Anticoagulation

Apr 2, 2010

Admitted for LOC – ICU intubation x 2 weeks

CKD 2° diabetic nephropathy

Heparin 5000 units SC Q8H

Apr 22 Dialysis initiated – R IJ inserted - radiologist noted incidental

finding of R IJ vein thrombosis (from previous ICU catheter)

Heparin 5000 units SC Q8H

May 1 Heme consult

Doppler R neck negative

Dalteparin 5000 units SC daily

 57  yo  male,  95  kg,  paraplegic  

June 2 Anti-Xa Level > 2 units/mL (13 h post dose)

Hold x 24 h, then

Dalteparin 2500 U SC OD June 5 Patient discharged

(39)

Conclusion  –  An#coagulant  Choices  in  

Renal  Impairment  (eGFR  <  30  mL/min)  

VTE  Treatment    

–  Unfrac0onated  heparin  IV  preferred  in  hospital  

–  LMWH  (monitor  an0-­‐Xa  levels  with  long-­‐term  therapy)  

•  Tinzaparin  –  full  dose  (up  to  10d)  

•  Enoxaparin  –  1/2  dose  (1  mg/kg  SC  daily)  

VTE  Prophylaxis  

–  Heparin  5000  units  SC  Q8-­‐12H  

–  Apixaban  –  Avoid  <  15  mL/min    

–  LMWH  

•  Tinzaparin  –  no  dose  restric0ons  

•  Dalteparin  –  5000  units  SC  OD  up  to  10  days  (↓2500  units  if  low  risk)   •  Enoxaparin  –  30  mg  SC  daily  (1/2  dose)  

References

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