Pulmonary embolism
See product literature or thromboprophylaxis guidelines.
See product literature or thromboprophylaxis guidelines.
See product literature or thromboprophylaxis guidelines.
See product literature or thromboprophylaxis guidelines.
See product literature or thromboprophylaxis guidelines.
See product literature or thromboprophylaxis guidelines.
See product literature or thromboprophylaxis guidelines.
For use in heparin infusions where immediate anticoagulant effect is needed or reversibility is required.
See product literature or thromboprohylaxis guidelines.
See product literature or thromboprohylaxis guidelines.
When patients have heparin-induced thrombocytopenia type II requiring parenteral antithrombotic treatment.
See product literature or thromboprohylaxis guidelines.
Prescribing Notes:
- See SIGN publication number 129 (Antithrombotic Therapy).
- Treatment with unfractionated heparin is continued until no longer required, or until warfarin takes effect (at least 3 days).
- Heparin is monitored using activated partial thromboplastin time (APTT) to give a patient/control ratio of 2.0-3.0.
- Low molecular weight heparin does not require APTT monitoring; if necessary, anti-factor Xa can be monitored.
- Heparins may induce thrombocytopenia. Serial platelet counts should be measured if heparin is given for longer than 5 days (or sooner if previously exposed), and heparin stopped if thrombocytopenia develops.
- Protamine sulphate reverses the effects of unfractionated heparin, but only partially reverses the effects of low molecular weight heparins.
- Refer to Edinburgh cancer centre antithrombotic guidelines for guidance on prophylaxis and treatment of PE in patients with active cancer.
History Notes
16/02/2022
East Region Formulary content agreed.
Treatment of PE: 10mg twice daily for 7 days, then 5mg twice daily. Following 7 days of a treatment dose with a LMWH, patient may be switched to 5mg twice daily.
Long term prevention of DVT/PE (following completion of 6 months of 5mg twice daily) 2.5mg twice daily.
Treatment of PE: 10mg twice daily for 7 days, then 5mg twice daily. Following 7 days of a treatment dose with a LMWH, patient may be switched to 5mg twice daily.
Long term prevention of DVT/PE (following completion of 6 months of 5mg twice daily) 2.5mg twice daily.
Where once daily dosing is an advantage.
60mg once daily. Treatment should follow initial use of parenteral anticoagulant at treatment dose for 5 days.
Dose should be adjusted as detailed in prescribing notes.
60mg once daily. Treatment should follow initial use of parenteral anticoagulant at treatment dose for 5 days.
Dose should be adjusted as detailed in prescribing notes.
60mg once daily. Treatment should follow initial use of parenteral anticoagulant at treatment dose for 5 days.
Dose should be adjusted as detailed in prescribing notes.
Dose is adjusted according to the INR.
Dose is adjusted according to the INR.
Dose is adjusted according to the INR.
Dose is adjusted according to the INR.
Prescribing Notes:
- The warfarin dose is adjusted according to the international normalised ratio (INR). The target INR should be clearly identified at initiation of therapy.
- The plasma half-life of warfarin is 35 hours; a steady anticoagulant effect is achieved after about one week. If immediate anticoagulation is required, heparin or treatment dose of LMWH must be given concomitantly.
- Indication and duration of treatment should be clearly recorded; the patient-held anticoagulant treatment booklet should be used.
- Patients with active cancer can be at high risk of both venous thromboembolism and bleeding events. In the absence of contra-indications, and after a careful assessment of the risks and benefits, apixiban may be considered for specialist initiation for patients with active cancer for either DVT or PE treatment and prevention of recurrence. Refer to Edinburgh cancer centre antithrombotic guidelines.
- There are many clinically important interactions with warfarin, edoxaban, rivaroxaban and apixaban; clinicians should consult BNF before prescribing.
- Vitamin K (phytomenadione) can be given to reverse the effects of warfarin but takes 6-12 hours to become effective. Immediate reversal of the anticoagulant effect of warfarin may be achieved with fresh frozen plasma or prothrombin complex concentrate. Specialist haematological advice should be sought. See BNF for full dosing details.
- Minor bleeding with apixaban, edoxaban and rivaroxaban can be managed by stopping the drug and the anticoagulant action should wear off after 24-48 hours. In the event of major bleeding, specialist haematological advice should be sought.
- When warfarin or DOAC therapy is initiated anti-platelet therapy is normally discontinued, except on specialist advice by cardiology to continue, this will be communicated in individual patient correspondence.
- Apixaban is not recommended in dialysed patients.
- Apixaban should not be used in any patient with severe renal impairment (creatinine clearance <15mL/min) and not for DVT/PE patients with creatinine clearance <30mL/min.
History Notes
16/02/2022
East Region Formulary content agreed.
Initially 10mg, to be given over 1–2 minutes, followed by (by intravenous infusion) 90mg, to be given over 2 hours, maximum 1.5mg/kg in patients less than 65kg.
Initially 10mg, to be given over 1–2 minutes, followed by (by intravenous infusion) 90mg, to be given over 2 hours, maximum 1.5mg/kg in patients less than 65kg.
Initially 10mg, to be given over 1–2 minutes, followed by (by intravenous infusion) 90mg, to be given over 2 hours, maximum 1.5mg/kg in patients less than 65kg.
Prescribing Notes:
- Please see local guidelines for further information.
- Alteplase is approved for the fibrinolytic treatment of acute ischaemic stroke. For use within 4.5 hours after onset of the stroke symptoms and after exclusion of intracranial haemorrhage.
- Alteplase 2mg/2ml vial formulation is approved for use in unblocking occluded central venous access devices including those used for haemodialysis. Only to be used when alteplase is the product of choice for this indication.
History Notes
16/02/2022
East Region Formulary content agreed.
On specialist advice.
Prescribing Notes:
- Protamine reverses the effects of unfractionated heparin but only partially reverses those of LMWH.
History Notes
16/02/2022
East Region Formulary content agreed.
Reversal of dabigatran.
On specialist advice.
Reversal of apixaban or rivaroxaban.
On specialist advice.
Prescribing Notes:
- Consideration should be given to the clinical risks associated with using the reversal agents. There is a risk of serious thrombotic events (MI, CVA, DVT/PE), need to assess the benefit to the patient and the clinical outcome.
History Notes
16/02/2022
East Region Formulary content agreed.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Prescribing Notes:
- Treatment with unfractionated heparin is continued until no longer required, or until warfarin takes effect (at least 3 days). Please contact haematology for advice.
- Unfractionated heparin is monitored using activated partial thromboplastin time (APTT) to give a patient/control ratio of 1.5-2.5.
- Low molecular weight heparin does not require APTT monitoring; if necessary, anti-factor Xa can be monitored.
- Heparins may induce two types of thrombocytopenia: the first, usually developing within 1-4 days of initiation, is acute, usually mild, and may resolve spontaneously. The second type has an immunological basis and is serious: it usually occurs after 7-11 days, or more quickly in previously exposed patients, and is often associated with serious thromboembolic complications or bleeding. Serial platelet counts should be measured if heparin/LMWH is given for longer than 5 days (or sooner if previously exposed), and heparin/LMWH stopped if thrombocytopenia develops. Haematology specialist advice should be sought.
- Protamine sulphate reverses the effects of unfractionated heparin, but only partially reverses the effects of low molecular weight heparins.
History Notes
19/06/2023
East Region Formulary content agreed - ERFC 07/06/2023.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Paediatric haematology should be contacted for dosing advice.
Prescribing Notes:
- Treatment with unfractionated heparin is continued until no longer required, or until warfarin takes effect (at least 3 days). Please contact haematology for advice.
- Choice of anticoagulation agent follows specialist advice considering risks v benefits.
- Treatment with rivaroxaban follows at least 5 days initial parenteral anticoagulation treatment.
History Notes
19/06/2023
East Region Formulary content agreed - ERFC 07/06/2023.