Patient Care Hematology & Oncology - October 2007 - (Page 13)

Bridge anticoagulation I LMWH dosing should be based on the patient’s on the agent used. Missing a dose will put the actual body weight and renal function. The usual patient at risk of thromboembolism. The patient will therapeutic dosage of enoxaparin is 1 mg/kg SC also need to be willing and able to perform selfq12h. For dalteparin, different dosages have been injection. Patient education is required for SC injecused: 100 IU/kg q12h, 200 IU/kg/d, and 120 IU/kg tion technique, appropriate disposal of syringes, and q12h.4 the possibility of side effects (eg, injection-site Renal dysfunction promotes accumulation of hematoma). LMWH. For this reason, the ACCP still recomThe manufacturers of LMWHs provide written mends the use of UFH to provide full therapeutic information on the specific administration techanticoagulation in patients with severe renal impairnique for each individual product. In general, these ment (creatinine clearance [CrCl] less than 30 injections are given the same way as any other SC mL/min). If an LMWH is used, monitoring of antiinjection (such as an SC insulin injection inserted at Xa levels should be considered in patients with a a 90-degree angle). The syringes are prefilled and CrCl less than 30 mL/min or in those with moderready to use. The preferred injection site is the ate renal impairment (CrCl of 30-60 mL/min) if the abdomen. For this, the patient should be sitting or LMWH is used for extended periods of more than 7 lying down in a comfortable position, and the injecto 10 days. At present, there are no clear TABLE 4 dosing guidelines for adjusting dalProposed bridge protocol using LMWH teparin or tinzaparin in patients with renal dysfunction. However, Days Day of Days the manufacturer of enoxaparin recpreceding surgery after Tasks ommends adjusting the dosage in 8 Assess need for bridging patients with a CrCl of 10 to 30 Assess risk mL/min. The recommended dosage Check INR is 1 mg/kg SC q24h. LMWHs Check LMWH availability should not be used in patients with Discontinue aspirin a CrCl of less than 10 mL/min. 4-6 Discontinue warfarin There are scant data on dosing obese patients with LMWH. Only a 2-4 Start LMWH limited number of patients with 1 Discontinue LMWH total body weight of more than 150 kg have been included in large ran0 Surgery domized clinical trials. For these patients, it is also reasonable to con1 Start LMWH sider anti-Xa levels for the purpose Start warfarin of dosage guiding.6 4-8 Check INR Patient understanding and comDiscontinue LMWH when INR pliance are essential to the safe use is in target range of bridge therapy with LMWH. Key: aPTT, activated partial thromboplastin time; INR, international normalized ratio; LMWH, LMWH needs to be given at speciflow-molecular-weight heparin. ic times (q12h or q24h), depending OCTOBER 2007 PATIENT CARE HEMATOLOGY & ONCOLOGY 13

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Patient Care - Hematology & Oncology - October 2007 Research Digest Contents Information for Authors Medicine in the News Strategies for Bridge Anticoagulation Therapy How to Integrate the New Cervical Cancer Guidelines into Practice Dermatology Case Challenge Clinical Clips Classified Advertising

Patient Care Hematology & Oncology - October 2007

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