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    Heparin Dose Adjustment in The Prescence of Renal Impairment

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    RPR KSV
    The document provides guidelines for adjusting heparin dosing for patients with renal impairment. It recommends reducing or avoiding certain heparin types for patients with a creatinine clearance below 30 mL/min or 15 mL/min depending on the drug. For prophylactic or therapeutic doses, the guidelines specify the adjusted dosing levels based on creatinine clearance and the heparin drug being used. It also provides guidance on switching between heparin types when an invasive procedure is needed for patients with more severe renal impairment.

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    Heparin Dose Adjustment in The Prescence of Renal Impairment

    Uploaded by

    RPR KSV
    15 views5 pages
    The document provides guidelines for adjusting heparin dosing for patients with renal impairment. It recommends reducing or avoiding certain heparin types for patients with a creatinine clearance below 30 mL/min or 15 mL/min depending on the drug. For prophylactic or therapeutic doses, the guidelines specify the adjusted dosing levels based on creatinine clearance and the heparin drug being used. It also provides guidance on switching between heparin types when an invasive procedure is needed for patients with more severe renal impairment.

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    The document provides guidelines for adjusting heparin dosing for patients with renal impairment. It recommends reducing or avoiding certain heparin types for patients with a creatinine clearance below 30 mL/min or 15 mL/min depending on the drug. For prophylactic or therapeutic doses, the guidelines specify the adjusted dosing levels based on creatinine clearance and the heparin drug being used. It also provides guidance on switching between heparin types when an invasive procedure is needed for patients with more severe renal impairment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    15 views5 pages

    Heparin Dose Adjustment in The Prescence of Renal Impairment

    Uploaded by

    RPR KSV
    The document provides guidelines for adjusting heparin dosing for patients with renal impairment. It recommends reducing or avoiding certain heparin types for patients with a creatinine clearance below 30 mL/min or 15 mL/min depending on the drug. For prophylactic or therapeutic doses, the guidelines specify the adjusted dosing levels based on creatinine clearance and the heparin drug being used. It also provides guidance on switching between heparin types when an invasive procedure is needed for patients with more severe renal impairment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 5

    CLINICAL GUIDELINE

    Heparin dose adjustment in the


    presence of renal impairment

    A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

    Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient
    characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased
    susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

    If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good
    practice to record these and communicate them to others involved in the care of the patient.

    Version Number: 5
    Does this version include
    Yes
    changes to clinical advice:
    Date Approved: 8th July 2020

    Date of Next Review: 31st July 2023

    Lead Author: Emily McQuarrie & Cristina Coelho

    Approval Group: Medicines Utilisation Subcommittee of ADTC

    Important Note:

    The Intranet version of this document is the only version that is maintained.
    Any printed copies should therefore be viewed as ‘Uncontrolled’ and as such, may not necessarily contain the
    latest updates and amendments.
    CLINICAL GUIDELINE

    Heparin Dose Adjustment


    Renal Impairment

    A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.


    Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient
    characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased
    susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.
    If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good
    practice to record these and communicate them to others involved in the care of the patient.

    Version Number 5 Yes


    Does this version include changes to clinical Yes
    advice
    Date Approved: July
    Date of Next Review 31st July 2023
    Lead Author: Emily McQuarrie, Cristina Coelho
    Approval Group: ADTC

    Important Note:
    The Intranet version of this document is the only version that is maintained.
    Any printed copies should therefore be viewed as ‘Uncontrolled’ and as such, may not necessarily contain
    the latest updates and amendments.

    Heparin Dose Adjustment Renal g20 1/4


    HEPARIN DOSE ADJUSTMENT
    IN THE PRESENCE OF RENAL IMPAIRMENT IN ADULTS

    Heparin and heparin-like anticoagulants (unfractionated heparin (UFH), low molecular weight heparins (LMWH) and
    the pentasaccharide, fondaparinux) vary considerably in their glycosaminoglycan composition, specifically their
    average chain size (UFH > LMWH > fondaparinux). Even within the LMWH group there can be subtle differences in
    average chain size (tinzaparin > dalteparin > enoxaparin). These differences have important effects both on the
    antithrombin-mediated target specificity and dependence on renal clearance – smaller heparins having a higher
    anti-factor Xa: anti-factor IIa ratio and a greater dependence on renal clearance. The latter is very relevant when
    prescribing these agents, either at prophylactic or therapeutic doses, for patients with substantially reduced kidney
    function (CrCl<30mL/min) as observational data demonstrate clinically important increase in bleeding complications
    of anticoagulation in this group of patients. For this reason, in-patients in the NHS GGC renal unit with chronic
    kidney disease and CrCl <30mL/min do not routinely receive pharmaceutical thromboprophylaxis when admitted for
    non-operative reasons unless there are other risk factors for thrombosis.

    Within NHS GGC the heparin agent of choice may vary between treatment and prophylaxis and for different
    indications – please consult NHS GGC Formulary or Therapeutics Handbook for preferred agent of choice. Based
    on relevant SPC guidance and limited additional literature the following recommendations are offered.

    Note that this guideline is for adult non-pregnant patients only.

    PROPHYLACTIC HEPARIN DOSING


    For dose adjustments in adult patients with very low or very high body weight,
    refer to GGC guideline on Staffnet – Clinical Guideline Repository
    CrCl (ml/min)
    GGC CrCl calculator available here

    ≥ 30 ml/min < 30 ml/min

    20mg once daily* if CrCl 30-15 ml/min


    Enoxaparin 40mg once daily AVOID if CrCl < 15 ml/min
    Use an alternative LMWH
    5,000 units once daily* if CrCl 30-15 ml/min
    Dalteparin 5,000 units once daily
    2,500 units once daily* if CrCl < 15 ml/min
    3,500 / 4,500 units once daily* as per indication
    Tinzaparin
    AVOID if CrCl < 20ml/min, use an alternative LMWH
    2.5 mg once daily if CrCl > 50 ml/min
    Fondaparinux 1.5 mg once daily if CrCl 50-20 ml/min
    AVOID if CrCl < 20 ml/min, use a suitable LMWH
    *If CrCl < 30ml/min and prophylactic LMWH treatment has continued for ≥10 days, re-assess anti-Xa activity after 10th dose of LMWH, to
    ensure there has been no significant drug accumulation (target 4h peak level: 0.1 - 0.4 units/ml)

    Heparin Dose Adjustment Renal g20 2/4


    THERAPEUTIC HEPARIN DOSING
    If a patient with a CrCl < 20 ml/min on a therapeutic LMWH regimen, which cannot be omitted for 36-48h, is
    scheduled for an invasive procedure (including small procedures such as a biopsy or central line insertion) it is
    recommended that the patient is switched to an UFH regimen prior to the procedure as follows:

    • IV UFH is started 20-24h after the last dose of therapeutic LMWH


    • IV UFH is stopped 6h prior to the procedure
    • IV UFH is restarted, assuming adequate haemostasis, 4-6h post procedure

    There are different concentrations of UFH currently available – only the 1000 units/ml preparation should be used at
    all times to reduce the risk of dose errors and serious clinical incidents.

    If you require further advice consult Therapeutics Handbook or contact haematology.

    For dose adjustments in adult patients with very low or very high body weight,
    refer to GGC guideline on Staffnet – Clinical Guideline Repository
    CrCl (ml/min)
    GGC CrCl calculator available here

    ≥ 30 ml/min 30-10 ml/min < 10 ml/min

    Dalteparin 200 units/kg once daily 200 units/kg once daily*


    (weight-banded dosing) [max 18,000 units] [max 18,000 units]
    Due to lack of evidence
    Consider dalteparin Consider dalteparin suggest use of UFH#
    100units/Kg twice daily in 100units/Kg twice daily in
    patients with high bleeding risk patients with high bleeding risk See page 4 for
    Enoxaparin VTE: 1.5 mg/kg once daily VTE: 1 mg/kg once daily* recommendations for

    Consider enoxaparin anticoagulation prescribing


    (weight-banded dosing) AVOID if CrCl < 15 ml/min
    1mg/Kg twice daily in patients during haemodialysis
    Use an alternative LMWH
    with high bleeding risk or
    patients perceived to be at high
    risk of recurrent VTE ACS: 1mg/kg once daily*
    (remains treatment of
    #
    In the Renal Unit enoxaparin
    ACS: 1 mg/kg twice daily choice if CrCl < 15 ml/min)
    1mg/kg once daily is regarded
    Tinzaparin 175 units/kg once daily 175 units/kg once daily* as an acceptable alternative
    AVOID if CrCl < 20 ml/min
    Use an alternative LMWH
    Fondaparinux SVT: 2.5 mg once daily if CrCl > 50 (1.5 mg if CrCl 20-50 ml/min)
    ACS: 2.5mg once daily if CrCl ≥20ml/min
    AVOID if CrCl <20 ml/min, use a suitable LMWH
    Unfractionated heparin **Use 1000 units/ml preparation at all times**
    (UFH) Loading IV dose: 5,000 units, if appropriate
    (intravenous Na Heparin) Maintenance IV infusion: start at 18 units/kg/h, check APTT ratio 6 hours after
    commencement of infusion, and 4 hours after any change in infusion rate, then daily
    (target APTT ration: 1.8-2.6)
    VTE: venous thrombosis; SVT: superficial vein thrombosis; ACS: acute coronary syndrome; UFH: unfractionated heparin
    *If CrCl < 30 ml/min consider assessing anti-Xa activity after 3rd dose (to confirm therapeutic levels have been achieved) and after 8-10th
    dose to ensure there has been no significant drug accumulation (target 4h peak level: 0.5 – 1.2 units/ml)

    Heparin Dose Adjustment Renal g20 3/4


    USE OF HEPARIN DURING HAEMODIALYSIS PROCEDURES
    If not on regular anticoagulation for other indications, haemodialysis patients should be considered for
    anticoagulation for the prevention of clotting of the extracorporeal circuit.

    Within NHS GGC the LMWH of choice for use during haemodialysis is subject to regular review. Please seek advice
    from renal team before prescribing.

    Tinzaparin dose regimen:


    Tinzaparin 2,500 units, if dialysis ≤ 4h
    Tinzaparin 3,500 units, if dialysis > 4h, or circuit clotting on 2,500 units

    Dalteparin dose regimen:


    If dry weight ≤ 60Kg 2,500 units
    If dry weight > 60Kg 5,000 units
    Please note that dalteparin dose is not dependent on duration of dialysis.

    When LMWH is used for haemodialysis anticoagulation, routine monitoring of anti-Xa activity is not required.

    Authors: Dr Emily McQuarrie, Cristina Coelho and Kathryn McCormick on behalf of NHS GGC Thrombosis
    Committee (with input from Dr Catherine Bagot)
    Approved by: Medicines Utilisation Sub-Committee, NHS GGC ADTC
    Review date: July 2023

    Heparin Dose Adjustment Renal g20 4/4

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