NON-HEPARIN ANTICOAGULANTS

• Anticoagulation in patients with Heparin Induced Thrombocytopenia (HIT)
• see HIT guideline
• Argatroban is preferred alternative anticoagulant in patients with HIT
• For advice, contact consultant haematologist

• Preferred alternative anticoagulant in patients with HIT
• Direct thrombin inhibitor with a half-life of 50 min
• Eliminated by hepato-biliary route

Administration

• Check baseline platelet count and APTT
• No dose modification in patients with renal impairment
• Specific dosage protocol for patients on haemodialysis, contact haematologist
• Use with caution in patients in critical care and hepatic impairment
• Contraindicated in patients with severe hepatic impairment
• If patient bleeds, contact consultant haematologist

IV infusion by syringe pump

• Preparation: 50mg/50ml (1mg/mL) solution for infusion – ready to use
• Administer via a syringe driver

Dosage

• Maximum dose 10 microgram/kg/min

• Danaparoid is a low-molecular-weight heparinoid, chemically distinct from heparin
• Use to treat suspected or proven HIT (with or without thrombosis)
• Use to prevent venous thrombosis in patients with a history of HIT
• If patient bleeds, contact consultant haematologist

Administration

• For patients undergoing dialysis, discuss with haematology
• Check baseline platelet count and APTT 

Bolus preparation

• Take 4500 units (3.6 mL of 1250 units/mL) danaparoid sodium injection
• make up to 45 mL in a syringe with sodium chloride 0.9% or glucose 5% = 100 units/mL
• The diluted solution is stable for 24 hr

• Use in HIT is unlicensed. Seek haematology advice before prescribing
• Fondaparinux is an indirect anti-Xa inhibitor and has a half-life of 17–20 hr
• Avoid in patients with renal impairment, use argatroban instead
• Before starting, check baseline platelet count and APTT, renal function
• If patient bleeds, contact consultant haematologist

Fondaparinux dosing for adult patients with HIT

• If body weight <50 kg, give 5 mg SC once daily
• If body weight 50 – 100 kg, give 7.5 mg SC once daily
• If body weight >100 kg, give 10 mg SC once daily
• If use in patients with renal impairment unavoidable, reduce dose and monitor anti-Xa levels

• Use in HIT is unlicensed. Seek haematology advice before prescribing
• Bivalirudin is a direct thrombin inhibitor licensed for use in coronary interventions
• it has a short half-life of 30–40 min which can be prolonged to 3 hr in patients with severe renal impairment
• for patients with renal impairment, use argatroban
• elimination of bivalirudin is by enzymic metabolism and renal excretion. No dose adjustment is required for hepatic impairment
• there is no known antidote
• rare cases of anaphylactic reaction have been associated with IV bolus or infusion
• Before starting infusion, obtain baseline platelet count and APTT
• If patient bleeds, contact consultant haematologist

Preparation

• 250mg powder for reconstitution for injection or infusion 

Administration for HIT

• Check baseline platelet count and APTT, renal function
• Reconstitute each 250mg vial with 5ml water for injection
• swirl gently until completely dissolved and the solution is clear
• Withdraw 5ml from the vial, and further dilute to a total volume of 50ml with glucose 5% or sodium chloride 0.9%
• gives a final concentration of 5mg/ml
• For HIT, given by intravenous infusion via infusion pump

Dosage for HIT