|THROMBOEMBOLIC DISORDER TREATMENTS: WITHOUT DVT/PE|
|Generic||Brand||Indication||Usual Adult Dosing|
|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%).
|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
|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.
|warfarin||Coumadin||Prophylaxis and treatment of 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 dose.|
|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: consider reducing dose to 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.|
|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|
|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.|
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. 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. 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.|
|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)|
|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.|
|Tissue Plasminogen Activators (tPA)|
|alteplase||Activase||Management of acute MI||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.|
|Management of acute ischemic stroke||Initiate within 3hrs of symptom onset. 0.9mg/kg (max 90mg) infused over 60min with 10% of total dose given as initial IV bolus over 1min.|
|reteplase||Retavase||Management of acute MI||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.|
Key: ACS = acute coronary syndrome; ACT = activated clotting time; AMI = acute myocardial infarction; CV = cardiovascular; HIT = heparin-induced thrombocytopenia; HITTS = HIT and thrombosis syndrome; MI = myocardial infarction; 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.
This article originally appeared on MPR