Thromboembolic Disorder Treatments: Without DVT/PE

THROMBOEMBOLIC DISORDER TREATMENTS: WITHOUT DVT/PE
Generic Brand Indication Usual Adult Dosing
ANTICOAGULANTS
Anticoagulant Proteins
protein C concentrate [human] Ceprotin Prophylaxis and treatment of venous thrombosis and purpura fulminans in severe
congenital protein C deficiency

Individualize. ≥10kg: max infusion rate 2mL/min.

Acute episodes/short term prophylaxis: initially 100−120 IU/kg, then
60−80 IU/kg every 6hrs for 3 doses (titrate to maintain target peak protein C
activity of 100%); maintenance: 45−60 IU/kg every 6 or 12hrs (After resolution of
acute episode, continue patient on same dose to maintain trough protein C level above 25%
for duration of therapy); continue until desired anticoagulation achieved.

Long-term prophylaxis: 45−60 IU/kg every 12hrs (maintain trough
protein C level above 25%).

Antithrombins
antithrombin [recombi
nant]
ATryn Prevention of peri-operative and peri-partum thromboembolic events in hereditary
antithrombin deficient patients
Individualize. Administer loading dose as 15min IV infusion, followed by
continuous IV infusion of maintenance dose. Monitor antithrombin activity once or twice
daily and adjust to maintain antithrombin activity between 80−120%. See full
labeling.
antithrombin III [human] Thrombate
 III
Treatment of hereditary antithrombin III deficiency (AT‑III) in surgical or
obstetrical procedures or patients who suffer from thromboembolism
Individualize. Dose (units required) = [desired (% of normal) − baseline
(% of normal) AT‑III level] × weight (kg)/1.4.

Give by IV infusion over 10−20min. Loading dose: increase AT‑III to 120%
of normal. Subsequent dose should be based on AT‑III levels obtained 20min post-infusion,
every 12hrs, and before the next dose. Maintain AT‑III levels at 80−120% of normal for
2−8 days. See full labeling.

Coumarins
warfarin Coumadin Thromboembolic complications of atrial
fibrillation and/or cardiac valve replacement
Individualize. Initially 2–5mg daily. Usual maintenance: 2–10mg daily; adjust based on INR. CYP2C9 or VKORC1 enzyme variations, elderly, debilitated, Asians: use lower initial and maintenance doses.
Reduce risk of death, recurrent MI, and thromboembolic events post‑MI
Direct Thrombin Inhibitors
argatroban Prophylaxis and treatment of thrombosis in HIT/HITTS Before administering, discontinue heparin and obtain a baseline aPTT. Initially
2mcg/kg/min continuous IV infusion; check aPTT 2hrs after starting; titrate to 1.5−3x
baseline aPTT (max 100sec); max 10mcg/kg/min.
PCI with or at risk of HIT/HITTS Initially 25mcg/kg/min by IV infusion, and a 350mcg/kg bolus by large
bore IV line over 3−5min; ACT should be checked 5−10min after bolus, and titrate
to therapeutic ACT of 300−450sec.
bivalirudin Angiomax Unstable angina undergoing PTCA 0.75mg/kg IV bolus (may give additional 0.3mg/kg bolus after 5mins, if needed in those without HIT/HITTS),
followed by 1.75mg/kg/hr for duration of procedure. May continue infusion up to 4hrs
post‑op; after 4hrs, may give additional infusion of 0.2mg/kg/hr up to 20hrs, if needed.
Give with aspirin 300−325mg daily. Renal impairment: CrCl <30mL/min:
reduce infusion rate to 1mg/kg/hr; hemodialysis: 0.25mg/kg/hr.
PCI with provisional GP IIb/IIIa blocker use
PCI with or at risk of HIT/HITTS
dabigatran Pradaxa Reduce risk of stroke and systemic embolism in non-valvular atrial fibrillation CrCl>30mL/min: 150mg twice daily. Renal impairment (CrCl 15−30mL/min): 75mg
twice daily; CrCl<15mL/min or on dialysis: not recommended. Moderate renal impairment (CrCl 30–50mL/min) with concomitant dronedarone or systemic ketoconazole: 75mg twice daily. CrCl <30mL/min with concomitant P-gp inhibitors: avoid.
lepirudin Refludan HIT and associated thromboembolic disease ≤110kg: Initial 0.4mg/kg slow IV bolus inj for 15−20sec, then
0.15mg/kg/hr as continuous infusion for 2−10 days or longer if needed. >110kg: max
initial bolus dose 44mg; max initial infusion dose 16.5mg/hr.
Factor Xa Inhibitors
apixaban Eliquis Reduce risk of stroke and systemic embolism in non-valvular atrial fibrillation 5mg twice daily; 2.5mg twice daily if patient has any 2 of the following: age
≥80yrs, ≤60kg, or creatinine ≥1.5mg/dL.
rivaroxaban Xarelto Reduce risk of stroke and systemic embolism in non-valvular atrial fibrillation CrCl >50mL/min: 20mg once daily with PM meal; CrCl 15–50mL/min: 15mg once daily with PM meal.
Reduce risk of major CV events in chronic CAD or PAD in combination with aspirin 2.5mg twice daily with aspirin.
Low Molecular Weight Heparins
dalteparin Fragmin Prophylaxis of ischemic complications of unstable angina and non-Q‑wave MI 120 IU/kg SC (max 10,000 IU) every 12hrs until stabilized with aspirin
75−165mg once daily for 5−8 days.
enoxaparin Lovenox Prophylaxis of ischemic complications of unstable angina and non-Q‑wave MI 1mg/kg SC every 12hrs for 2−8 days; with aspirin 100−325mg once
daily.
Acute STEMI (patients <75 yrs); with or without subsequent PCI 30mg IV bolus + 1mg/kg SC dose then 1mg/kg SC every 12hrs at least
8 days (max 100mg for first 2 doses only); with aspirin 75−325mg once daily. If
last dose given <8hrs before balloon inflation, no dose needed; >8hrs before balloon
inflation: give 0.3mg/kg IV bolus.
Acute STEMI (patients ≥75 yrs) 0.75mg/kg SC every 12hrs (no bolus) at least 8 days (max 75mg for
first 2 doses only); with aspirin 75−325mg once daily.
Generic Brand Indication Usual Adult Dosing
ANTIPLATELETS
dipyridamole Persantine Adjunct prophylactic therapy to coumarin anticoagulants after cardiac valve
replacement
75−100mg four times a day as an adjunct to usual warfarin therapy.
Antiplatelet +
Nonsteroidal Antiinflammatory Drugs (NSAID)
dipyridamole + aspirin Aggrenox Reduce risk of stroke after transient ischemia of the brain or complete
ischemic stroke due to thrombosis
1 cap twice daily (AM and PM). Alternative if intolerable headaches:
switch to 1 cap at bedtime and low-dose aspirin in AM; return to usual regimen within
1wk.
Glycoprotein IIb/IIIa (GP IIb/IIIa) Blockers
abciximab Reopro Adjunct to PCI for prevention of cardiac ischemic complications 0.25mg/kg IV bolus over 10−60min before start of PCI, then a continuous IV
infusion of 0.125mcg/kg/min (max 10mcg/min) for 12hrs. Use with heparin and aspirin.
Unstable angina not responding to conventional therapy, undergoing PCI
within 24hrs
0.25mg/kg IV bolus, then 10mcg/min IV infusion over 18−24hr
concluding 1hr after PCI.
eptifibatide Integrilin ACS: managed medically and those undergoing PCI 180mcg/kg IV bolus, then continuous IV infusion of 2mcg/kg/min until discharge
or CABG surgery, up to 72hrs. If PCI planned, continue infusion until discharge, or for up
to 18−24hrs after procedure, whichever comes first, allowing up to 96hrs of therapy. CrCl <50mL/min: reduce rate to 1mcg/kg/min.
Concomitant use with aspirin and heparin.
PCI, including those undergoing intracoronary stenting 180mcg/kg IV bolus immediately before PCI followed by 2mcg/kg/min
continuous infusion; repeat 180mcg/kg IV bolus 10min after the 1st bolus; continue infusion
until discharge, or for up to 18−24hrs, whichever comes first, minimum 12hr-infusion
recommended. CrCl <50mL/min: reduce rate to 1mcg/kg/min. Concomitant use with aspirin and heparin
tirofiban Aggrastat Reduce thrombotic CV events in patients with non-ST elevation ACS 25mcg/kg IV within 5mins, then 0.15mcg/kg/min for up to 18hrs. Renal impairment CrCl ≤60mL/min 25mcg/kg IV within 5mins, then 0.075mcg/kg/min for up to 18hrs.
Platelet Reducing Agents
anagrelide Agrylin Treatment of thrombocythemia secondary to myeloproliferative disorders Initially 0.5mg four times daily or 1mg twice daily for ≥1wk. May increase
dose by 0.5mg/day weekly to maintain normal platelet count; max 10mg/day or 2.5mg/dose. Moderate hepatic impairment: initially 0.5mg/day.
Protease-Activated Receptor-1 (PAR-1) Antagonist
vorapaxar Zontivity Reduce thrombotic CV events in patients with history of MI or with peripheral arterial disease 2.08mg once daily. Take with aspirin and/or clopidogrel based on indications.
P2Y12 Platelet Inhibitor (cyclopentyltriazolopyrimidine)
ticagrelor Brilinta Reduce thrombotic CV events in patients with ACS or history of MI Loading dose: 180mg once. Maintenance: 90mg twice daily for 1yr, then 60mg twice daily thereafter. Take with aspirin dose of 75–100mg daily.
P2Y12 Platelet Inhibitor (thienopyridines)
clopidogrel Plavix Acute coronary syndrome (ACS) Initially one 300mg loading dose, then 75mg once daily; take with aspirin. CYP2C19 poor metabolizers: consider alternatives.
Recent MI, stroke or established peripheral arterial disease

75mg once daily.

CYP2C19 poor metabolizers: consider alternatives.

prasugrel Effient Reduce thrombotic CV events in patients with ACS, managed with PCI Loading dose: 60mg once. Maintenance: 10mg once daily.
<60kg: consider 5mg once daily. Take with aspirin (75mg−325mg daily)
ticlopidine

Reduce risk of thrombotic stroke in aspirin intolerant patients who’ve had
a completed thrombotic stroke
250mg twice daily with food.
Reduce incidence of subacute stent thrombosis for successful coronary
artery stenting
250mg twice daily with food together with antiplatelet doses of
aspirin for up to 30 days of therapy following successful stent implantation.
THROMBOLYTICS
Tissue Plasminogen Activators (tPA)
alteplase Activase Treatment of AMI to reduce mortality and heart failure Max 100mg/dose. Accelerated infusion: ≤67kg: 15mg IV bolus, then
0.75mg/kg (max 50mg) infused over 30min, then 0.5mg/kg (max 35mg) over 60min. >67kg: 15mg
IV bolus, then 50mg infused over 30min, then 35mg infused over 60min; 3‑hour
infusion:
(≥65kg): 60mg infused in the 1st hour (of which 6−10mg is given as
bolus), then 20mg/hr for 2hrs; (<65kg): 1.25mg/kg over 3hrs (of which 0.075mg/kg as bolus, 0.675mg/kg for the rest of the 1st hour, then 0.25mg/kg/hr for 2hrs). May use concomitantly with heparin.
Treatment of acute ischemic stroke Initiate within 3hrs of symptom onset. 0.9mg/kg (max 90mg total dose) infused
over 60min with 10% of total dose given as initial IV bolus over 1min.
reteplase Retavase Improve ventricular function and reduce CHF and mortality associated with AMI 10 IU as IV bolus over 2min; repeat dose 30min after initiation of 1st
bolus.
tenecteplase TNKase Reduce mortality associated with AMI Give as single IV bolus over 5sec. <60kg: 30mg; ≥60kg−<70kg: 35mg;
≥70kg−<80kg: 40mg; ≥80kg−<90kg: 45mg; ≥90kg: 50kg. Max: 50mg.
NOTES

Key: ACS = acute coronary syndrome;
ACT = activated clotting time; AMI = acute myocardial infarction; CAD = coronary artery disease; CV = cardiovascular; HIT = heparin-induced thrombocytopenia; HITTS = HIT and thrombosis syndrome; MI = myocardial infarction; PAD = peripheral artery disease; PCI = percutaneous coronary intervention; PM = evening; PTCA = percutaneous transluminal coronary angioplasty; SC = subcutaneous

Not an inclusive list of medications, official indications, and/or dosing
details. Please see drug monograph at www.eMPR.com and/or
contact company for full drug labeling.

(Rev. 12/2018)