Venous thromboembolism
See product literature or thromboprohylaxis guidelines.
See product literature or thromboprohylaxis guidelines.
See product literature or thromboprohylaxis guidelines.
See product literature or thromboprohylaxis guidelines.
See product literature or thromboprohylaxis guidelines.
See product literature or thromboprohylaxis guidelines.
See product literature or thromboprohylaxis guidelines.
For use in heparin infusions where immediate anticoagulation effect is needed or reversibility is required.
See product literature or thromboprohylaxis guidelines.
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 DVT in patients with active cancer.
History Notes
16/02/2022
East Region Formulary content agreed.
10mg once daily, starting 6 to 10 hours after surgery, provided that haemostasis has been established. 5 weeks treatment for hip replacement and 2 weeks treatment for knee replacement.
2.5mg twice daily for 14 days after knee replacement surgery; 2.5mg twice daily for 35 days after hip replacement surgery.
Prescribing Notes:
- Rivaroxaban or apixaban are approved for specialist use only, in hip and knee replacement surgery, for prophylaxis of venous thromboembolism.
History Notes
16/02/2022
East Region Formulary content agreed.
Treatment of DVT: 10mg twice daily for 7 days, then 5mg twice daily. If commencing therapy following at least 7 days of a treatment dose with a LMWH, patient may be switched immediately to 5mg twice daily.
Prevention of DVT/PE (following completion of 6 months of 5mg twice daily) 2.5mg twice daily.
Treatment of DVT: 10mg twice daily for 7 days, then 5mg twice daily. If commencing therapy following at least 7 days of a treatment dose with a LMWH, patient may be switched immediately to 5mg twice daily.
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 a 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 a 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 a 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 indication, target INR and duration of therapy should be clearly identified at initiation of therapy and clearly noted in patient held anticoagulation booklet.
- 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.
- 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.
- Edoxaban has a rapid onset of action; patients will be fully anticoagulated within 1-2 hours of their first dose. For guidance on patients switching from warfarin see summary of product characteristics or refer to local guidance.
- Edoxaban dose should be reduced to 30mg if body-weight reduces to 61kg and below.
- Edoxaban should be used to a maximum dose of 30mg once daily if creatinine clearance 15-50mL/minute and should be avoided if creatinine clearance is less than 15mL/minute. Please consult product literature or the BNF for monitoring requirements.
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.
- Choice of anticoagulation agent follows specialist advice considering risks v benefits.
- Treatment with rivaroxaban follows at least 5 days initial parenteral anticoagulation treatment.
- 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 is given for longer than 5 days (or sooner if previously exposed), and heparin 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.