Anticoagulants for the treatment of VTE
| . | Dosage . | Practical issues . |
|---|---|---|
| Parenteral agents | ||
| Unfractionated heparin | Sodium heparin: 80 IU/kg bolus dose followed by 18 IU/kg per hour by continuous infusion | aPTT ratio maintained between 1.5 to 2.0 per normal value. No issue with renal failure. |
| Calcium heparin: first dose 333 IU/kg followed by 250 IU/kg SC twice per day or body weight–adjusted with initial IV bolus* | No monitoring required. No issue with renal failure. No data on use with thrombolysis or embolectomy. | |
| Enoxaparin SC | 1.0 mg/kg every 12 hours or 1.5 mg/kg once per day | To be reduced in case of renal failure. No evidence for dose adjustment based on coagulation tests. |
| Tinzaparin SC | 175 IU/kg once per day | To be reduced in case of renal failure. No evidence for dose adjustment based on coagulation tests. |
| Dalteparin SC | 100 IU/kg every 12 hours or 200 IU/kg once per day | To be reduced in case of renal failure. No evidence for dose adjustment based on coagulation tests. |
| Nadroparin SC | 86 IU/kg every 12 hours or 171 IU/kg once per day | No adjustment in case of renal failure. |
| Fondaparinux SC | Once per day: 5 mg (body weight <50 kg); 7.5 mg (body weight 50-100 kg); 10 mg (body weight >100 kg) | Avoid in case of renal failure. No evidence for dose adjustment based on coagulation tests. |
| Oral compounds | ||
| Rivaroxaban | 15 mg twice per day for 3 weeks followed by 20 mg once per day | No data if creatinine clearance <30 mL/min. Reduced dose (rivaroxaban 10 mg once per day) effective for secondary prevention. |
| Apixaban | 10 mg twice per day for 1 week followed by 5 mg twice per day | Reduced dose (apixaban 2.5 mg twice per day) effective for secondary prevention. |
| Edoxaban | 60 mg once per day following 5 to 7 days of parenteral treatment | Reduce to 30 mg according to predefined criteria.† |
| Dabigatran | 150 mg twice per day following 5 to 7 days of parenteral treatment | No data if creatinine clearance <30 mL/min. |
| Vitamin K antagonists | To be overlapped with parenteral anticoagulants and INR adjusted | No issue with renal failure. Target INR, 2.0 to 3.0. |
| . | Dosage . | Practical issues . |
|---|---|---|
| Parenteral agents | ||
| Unfractionated heparin | Sodium heparin: 80 IU/kg bolus dose followed by 18 IU/kg per hour by continuous infusion | aPTT ratio maintained between 1.5 to 2.0 per normal value. No issue with renal failure. |
| Calcium heparin: first dose 333 IU/kg followed by 250 IU/kg SC twice per day or body weight–adjusted with initial IV bolus* | No monitoring required. No issue with renal failure. No data on use with thrombolysis or embolectomy. | |
| Enoxaparin SC | 1.0 mg/kg every 12 hours or 1.5 mg/kg once per day | To be reduced in case of renal failure. No evidence for dose adjustment based on coagulation tests. |
| Tinzaparin SC | 175 IU/kg once per day | To be reduced in case of renal failure. No evidence for dose adjustment based on coagulation tests. |
| Dalteparin SC | 100 IU/kg every 12 hours or 200 IU/kg once per day | To be reduced in case of renal failure. No evidence for dose adjustment based on coagulation tests. |
| Nadroparin SC | 86 IU/kg every 12 hours or 171 IU/kg once per day | No adjustment in case of renal failure. |
| Fondaparinux SC | Once per day: 5 mg (body weight <50 kg); 7.5 mg (body weight 50-100 kg); 10 mg (body weight >100 kg) | Avoid in case of renal failure. No evidence for dose adjustment based on coagulation tests. |
| Oral compounds | ||
| Rivaroxaban | 15 mg twice per day for 3 weeks followed by 20 mg once per day | No data if creatinine clearance <30 mL/min. Reduced dose (rivaroxaban 10 mg once per day) effective for secondary prevention. |
| Apixaban | 10 mg twice per day for 1 week followed by 5 mg twice per day | Reduced dose (apixaban 2.5 mg twice per day) effective for secondary prevention. |
| Edoxaban | 60 mg once per day following 5 to 7 days of parenteral treatment | Reduce to 30 mg according to predefined criteria.† |
| Dabigatran | 150 mg twice per day following 5 to 7 days of parenteral treatment | No data if creatinine clearance <30 mL/min. |
| Vitamin K antagonists | To be overlapped with parenteral anticoagulants and INR adjusted | No issue with renal failure. Target INR, 2.0 to 3.0. |
aPTT, activated partial thromboplastin time; INR, international normalized ratio; IU, international units; SC, subcutaneously.
Or body weight <50 kg: 4000 IU IV bolus plus 12 500 IU SC twice per day; body weight 50-70 kg: 5000 IU IV bolus plus 15 000 IU SC twice per day; body weight >70 kg: 6000 IU IV bolus plus 17 500 IU SC twice per day.
At least one among patient body weight ≤60 kg; creatinine clearance ≤50 mL/min; concomitant potent P-glycoprotein inhibitors.