2.5mg SC daily. INR target mg SC q 12 hr or 40mg daily. 10 mg PO q day (CrCl 30 ml/min). Avoid if < 30 ml/min. 2.

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1 Anticoagulation dosing at UCDMC (SC=subcutaneously; CI=continuous infusion) Indication Agent Dose Comments Prophylaxis Any or No bleeding risk factors see adult heparin (VTE prophylaxis) IV infusion order set Trauma 30 mg SC q 12 hr For patients over 100kg, can give 40mg SC q 12 hr Ortho-Trauma 30 mg SC q 12 hr Optional: 5000 units SC q 8-12hr For patients over 100kg, can give 40mg SC q 12 hr Orthopedic Joint Fondaparinux Warfarin 2.5mg SC daily INR target mg SC q 12 hr or 40mg daily Fondaparinux 2.5mg sq daily is an option in hip fractures Optional: 5000 units SC q 8-12hr 40mg dose once daily is if enoxaparin given pre-operative as well, or if it has been over 1 week after surgery 10 mg PO q day (CrCl 30 ml/min). Avoid if < 30 ml/min Not required to give dose with evening meal. First dose 6 10 hrs after surgery 2.5 mg PO q 12 hr First dose should be taken hrs after surgery Warfarin INR Orthopedic Spine 30 mg SC q 12 hr GI Surgery 40 mg SC q 24 hr Surgical Oncology 40 mg SC q 24 hr Burn Surgery 30mg SC q 12 hr Vascular Surgery 40mg SC q 24hr CT surgery 5,000 units SC q 8 12 hr Warfarin with target INR of 1.5 to 2 is another option. Bariatric Surgery : 40 mg SC pre-op and post OP 40 mg SC q 12hr for duration of stay. (If the patient is re-admitted within 30 days of surgery, but more than 7 days after the operation, use the currently approved LMWH) 5,000 units SC q 12 hr may be used post OP day mg SC q 12 hr or 40 mg SC q 24 hr May prefer 40mg SC q 24 hr on post-op day 1

2 GYN/GYN Oncology OB 40 mg SC q 24 hr may be considered at time of delivery. 30 mg SC q 12 hr or 40 mg SC q 24 hr. in selected situations after review by the anticoagulation service. Rehab Medicine Medicine HIT history Dalteparin Bivalirudin or Fondaparinux 5,000 units SC q 24 hr 40mg SC daily 5,000 units SC units q 8 hr 40mg SC daily Bivalirudin: Call Pharmacy to dose. Fondaparinux: 2.5mg SC q 24 hr Post delivery prophylaxis may continue for up to 6 to 8 weeks Elderly (age > 85 years old) or body weight < 50kg may use 5,000 units SC q 12 hr Anticoagulation, CPCS or hematology service approval required for fondaparinux

3 Treatment Any (Non HIT) CI See EMR order set VTE Treatment (all services) CI or see EMR VTE treatment order set. 1mg/kg SC twice daily (prefer 12 hours apart) Dabigatran 150 mg PO q 12 hr For CrCl 30-60ml/min, can reduce dose ~25%, or round down to next syringe size. For CrCl ml/min reduce dose to 1mg/kg once daily. For CrCl < 20ml/min or hemodialysis see below. considerations considerations. Dose must be given with food considerations. Use with caution if CrCl < 20 ml/min. Parenteral therapy should be provided for at least 5 days prior to initiating edoxaban for acutevte treatment. 15 mg PO q12 hr for first 21 days, then 20mg/day PO after 21 days 10 mg PO q 12 hr for 7 days, then 5mg PO q 12 hr after 7 days Pediatrics OB HIT Edoxaban CI or CI or DTI or Fondaparinux CrCl > 50 ml/min 60mg PO daily CrCl (or weight 60kg, or use of Pgp inhibitor 30mg PO daily < 15 ml/min No dosing recommendations see EMR order sets : 1mg/kg SC q 12 hr; Adjust to anti-factor Xa activity see EMR order set 1mg/kg SC q 12 hr. Adjusted to anti-factor Xa activity Call Anticoagulation Service for assistance 1.5mg/kg if age < 2 mo just prior to delivery Anticoagulation, CPCS or hematology approval required for fondaparinux

4 Atrial Fibrillation AF with CHADS 2 or history of embolic stroke or TIA Warfarin CI INR 2-3 see EMR ACS order set 1mg/kg SC q12 hr Thrombus concerns from ECHO or presence of a closure device despite a CHADS2 of 2 or less may still warrant LMWH Typically, no bolus for heparin is necessary For CrCl 30-60ml/min, can reduce dose ~25%, or round down to next syringe size. For CrCl ml/min reduce dose to 1mg/kg once daily. For CrCl < 20ml/min or hemodialysis see below. Dabigatran Dabigatran: mg PO q 12 hr (See renal impairment dosing below) considerations : 20mg/day PO (15mg/day if CrCl ml/min) Dose must be given with evening meal Ablation Acute Coronary Syndrome NSTEMI STEMI Edoxaban Warfarin or CI or intermittent bolus, or CI or intermittent bolus : 5mg PO q 12 hr CrCl > ml/min: 60mg PO daily CrCl ml/min: 30mg PO Daily < 15 ml/min No dosing recommendations INR to 1mg/kg SC q 12hr CI: See ACS order set bolus adjusted to ACT in cardiac cath. lab 1 mg/kg SC q 12 hr CI: See EMR ACS order set bolus adjusted to ACT in cardiac cath. Lab 1 mg/kg SC q12h If 2 of the following, give 2.5 mg PO q 12 hr: Age 80 years Body weight 60 kg SCr 1.5mg/dL See below for drug interactions and ESRD dosing For CrCl > 95 ml/min, warfarin preferred. Procedure may be performed with INR in target range 30 mg or up to 0.5 mg/kg enoxaparin IV at presentation Reduce dose in STEMI: (thrombolysis) Age > 75: No bolus, enoxaparin decreased to 0.75mg/kg SC q 12hr, CrCl ml/min: 1 mg/kg SC q 24 hr

5 Special Considerations: Dalteparin: Dalteparin may be used for patients who may be here for a limited stay and are on prior to admission for VTE treatment (e.g. Cancer Patients), or those who may be discharged and need 24 hour coverage while transitioning to a different anticoagulation regimen (warfarin and/or other LMWH) Dose: 200 units/kg/day SC if VTE event > 30 days. After 30 days, decrease dose to 150 units/kg/day. For VTE event < 1 month prior (200 units/kg) <57Kg: 10,000 units 57-68kg: 12,500 units 69-82kg: 15,000 units 83-98kg: 18,000 units kg: 20,000 units kg: 22,500 units kg: 25,000 units kg: 27,500 units kg: 30,000 units >150kg: Call CLOT service or pharmacy for dosing assistance For VTE related event > 1 month or other indications for treatment ( 150 units/kg) <57Kg: 7,500 units 57-68kg: 10,000 units 69-82kg: 12,500 units 83-98kg: 15,000 units kg: 18,000 units kg: 20,000 units kg: 22,500 units >150kg: Call CLOT service or pharmacy for dosing assistance LMWH Dose Rounding: < 50kg, Call primary service to adjust to nearest syringe size : Round up or down to nearest syringe based on assessment of thrombosis vs bleeding risk if > 50 kg. If CrCl ml/min, can decrease dose ~25% or round down to the next syringe size. Consider rounding down if renal impairment, higher bleeding risk, elderly, frail etc. Consider rounding up if normal renal function, higher clotting risk, young, few comorbidities etc. For obese patients, call Anticoagulation serv ice for dosing assistance VTE prophylaxis: In general, if wt > 100kg in surgical patients, a dose of 40mg SC twice daily can be considered, however it is unclear if the higher dose is warranted in the obsess medical patient. If the Medical patient is at high risk for thrombosis and morbidly obese, the higher prophylaxis dose can be considered. VTE treatment : In the setting of Obesity, cancer or high risk for thrombosis, twice daily (1mg/kg) is preferred. In lower risk pop ulations unable to tolerate twice daily, a regimen of 1.5mg/kg/day (CrCl above 30 ml/min) can be considered. Renal Impairment: (Use Cockcroft and Gault equation and total body weight for calculations) Dalteparin: No adjustment if CrCl > 20 ml/min : Scr 20-30: Decrease dose by 50%: Treatment 1mg/kg SC q 24 hr Prophylaxis 30mg SC q 24 hr Fondaparinux: Not recommended if the CrCl is below 30 ml/min.

6 CrCl < 20 ml/min for either enoxaparin, dalteparin or fondaparinux: Call the Anticoagulation service for assistance. Dabigatran: For Atrial Fibrillation: 150mg PO q 12hr if CrCl > 30 ml/min 75mg PO q 12 hr CrCl 15-30ml/min CrCl 30-50ml/min + P-gp inhibitor (dronedarone or systemic ketoconazole) Avoid < 15ml/min or dialysis: No recommendations CrCl ml/min + P-gp inhibitor (dronedarone or systemic ketoconazole) For DVT and PE treatment or prophylaxis : For VTE treatment, an initial 5-7 day of /LMWH should be given prior to transitioning to Dabigatran 150mg PO q 12 hr if CrCl > 30 ml/min Avoid CrCl < 30 ml/min or dialysis: No recommendations CrCl < 50 ml/min with concomitant use of P -gp inhibitors VTE Prophylaxis Ortho: Not recommended if CrCl < 30 ml/min VTE treatment: No bridge with initial /LMWH was required AF: Must give with evening meal 20mg PO daily if CrCl > 50 ml/min 15mg PO daily if CrCl 15-50ml/min Avoid if CrCl < 15 ml/min For Atrial Fibrillation: If 2 of the following, give 2.5 mg PO q 12 hr: Age 80 years Body weight 60 kg\ SCr 1.5mg/dL Reduce dose by 50% if the dose is greater than 2.5mg twice daily ESRD maintained on hemodialysis and atrial fibrillation: 5 mg twice daily Reduce dose to 2.5 mg twice daily if one of the following patient characteristics (age 80 years of body weight 60 kg) is present. Note: Not assessed in phase II trial and there may be potential for accumulation. Only a small amount is removed by hemodialysis. Edoxaban Renal adjustment depends on indication. See AF and VTE sections. In patients with a CrCl > 95ml/min. warfarin was better and thus has a preferred use indication over Pregnancy: Call Pharmacy or Anticoagulation service for dosing assistance Pediatrics: Call 6 th floor pharmacy or Anticoagulation Service for dosing assistance Approved by UCDHS Pharmacy & Therapeutics Committee 6/2015.

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