heparin monitoring guidelines

Phelan HA, Wolf SE, Norwood SH, et al. The heparin product or fondaparinux should be continued for at least five days and until the patient's international normalized ratio is at least 2.0 for two consecutive days. 4. MONITORING LOW MOLECULAR WEIGHT HEPARIN THERAPY For patients with renal dysfunction (creatinine clearance of <30 mL/min) No monitoring required G. Argatroban . 1 It exists as polymers of varying sizes (20,000 – 50,000 kDa) naturally, and as manufactured unfractionated heparin. Affiliation 1 Department of . Guidelines on the use and monitoring of heparin Br J Haematol. Practices considered include guidance on selection of initial dosing nomograms, Department of Health: Anticoagulation and prophylaxis using LMWH in adult inpatients . Inability of the activated partial thromboplastin time to predict heparin levels. When administering unfractionated heparin (UFH), therapeutic levels of anticoagulation must be achieved rapidly and maintained consistently in the therapeutic range. Kitchen S, Theaker J, Preston FE. Activated partial thromboplastin time. Anticoagulation guidelines for UW Medicine. title = "Guidelines on the use and monitoring of heparin.", abstract = "The guideline group was selected to be representative of UK-based medical experts. and/or Anti factor Xa level, however monitoring (including the test and frequency) should be according to local guidelines. 74 There is evidence that a 5-day course of heparin is as effective as a 10-day course 120121 (Table 7 ). Protamine Dosing Guidelines Page 1 of 2 Guidelines for Unfractionated Heparin Immediate Reversal Discontinue heparin infusion Calculate total amount of heparin received over the preceding 3 hours STAT protamine sulfate - see dosing recommendations below Time From Last Dose of Heparin Protamine Sulfate Dose If initiated within 30 minutes 11 . 1. MONITORING LOW MOLECULAR WEIGHT HEPARIN THERAPY For patients with renal dysfunction (creatinine clearance of <30 mL/min) GUIDELIES ADE SIMPLE AF 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation 5 Back to Table of Contents Section 4.1.1 - Selection of Antithrombotic Regimen Section 4.3 - Interruption and Bridging Anticoagulation Guidelines were developed using data from the McMaster group studies showing a heparin level of 0.2 to 0.4 IU/mL by protamine assay was equivalent to a level of 0.35 to 0.70 IU/mL using a factor Xa heparin assay. 4. 4. 33 One point-of-care system, the Hepcon Hemostasis Management System Plus (Medtronic . Green Top Guideline No. monitoring of anti-Xa levels (see below) until a stable level is achieved, with less frequent monitoring in situations where long term therapy is employed. A randomized, double-blinded, placebo-controlled pilot trial of anticoagulation in low-risk traumatic brain injury: the Delayed Versus Early heparin, is strongly associated with recent heparin exposure (within past 100 days, especially last 30 days).2 The decision to perform platelet count monitoring, and the intensity of such monitoring, depends on the patient's risk factors, particularly the type of heparin, duration of heparin therapy, and the type of patient. Heparin molecules range in molecular weight from 3,000 to 30,000 kDa with a mean of 15,000, which corresponds to approximately 45 saccharide units ( Fig 2 ). This page contains Clinical Practice Guidelines for the administration of Standard Heparin infusions, systemic lytic therapy and the management of a blocked central venous access device. Low molecular weight heparin (LMWH) is a class of medication used as an anticoagulant in diseases that feature thrombosis, as well as for prophylaxis in situations that lead to a high risk of thrombosis. General guidelines for monitoring these agents and 9 speciﬁc recommendations for laboratory monitoring of low-molecular-weight heparin and danaparoid are provid-ed, along with citation of the appropriate supporting lit-erature. Arch Intern Med. The two major side effects are bleeding and heparin-induced thrombocytopenia (HIT). The international. Anticoagulation Guidelines for Pediatric and Young Adult Patients with Covid-19 This guidance applies to patients admitted to the Children's Hospital with COVID-19. Because it can be given subcutaneously and does not require aPTT monitoring, LMWH permits outpatient treatment of conditions such as deep vein . 1. Heparin can be given either intravenously by continuous infusion, usinganinfusion pump, orbyintermittent subcutaneousinjection into the anteriororanterolateral wall of the abdomen near the iliac crest or thigh, using smallvolumesyringeswithsmallboreneedles so that aprecise dosecanbe delivered.'2 The recommended concentration for subcuta- Non-adherence to any anticoagulant therapy is an undesirable outcome, but this is particularly important for the DOACs given their short half-life. Point-of-Care Monitoring of Anticoagulation Therapy; Approved Guideline This document provides guidance to users and manufacturers of point-of-care coagulation devices for monitoring heparin and warfarin anticoagulant therapy, and to ensure reliable results comparable to those obtained by routine clinical laboratory testing. 9 This relationship formed the basis for recommendation of a 0.3 to 0.7 IU/mL therapeutic range for UH using an anti-Xa assay. It is heterogeneous with respect to molecular size, anticoagulant activity, and pharmacokinetic properties ( Table 1 ). 1. PTT may be used to monitor heparin as an alternative to anti-Xa levels in patients with hyperbilirubinemia, hemolysis, hypertriglyceridemia, or direct factor Xa inhibitor use that might interfere with anti-Xa levels. The guideline group was selected to be representative of UK- Issues for which a consensus was not reached at the Conference are also discussed. 2. Order Loading Bolus, if warranted. Prophylactic (low dose) heparin does not usually require monitoring. The guideline notes the potential for an additive effect of DOACs on screening tests during the first 24 to 36 hours, and recommends that alternative monitoring strategies for assessing heparin anticoagulation should be used, if required. Guideline update This guideline will be reviewed in 2008. It is well known that activated clotting time values diverge from heparin levels during the conduct of CPB, 36 leading society guidelines to recommend either monitoring actual heparin levels or redosing heparin at fixed intervals during prolonged CPB use. Heparin remains the most widely used parenteral antithrombotic. Direct thrombin inhibitor. Time to reassess guidelines for heparin assays. Order standard heparin infusion with starting rate defaulted based on indication. Audits of heparin monitoring practices indicate that dosage adjustments are frequently inadequate, and dosing practices can be improved by use of a simple and effective weight-adjusted dosage regimen. This speciﬁc chapter ad-dresses the practical management of heparins including low molecular weight heparins and fondaparinux. Send aPTT 2 hours after initiation of therapy. . For each anticoagulant a list of the most common practice related Initial: 2 mcg/kg/min continuous IV infusion (0.5 mcg/kg/min if moderate hepatic impairment).. Anticoagulation Monitoring • Anti‐factor Xa levels were markedly elevated. Routine Labs and Monitoring a. Heparin assay 6 hours after initiating heparin b. Heparin assay 6 hours after each dosage change, until 2 consecutive therapeutic levels are reached at a constant rate of infusion, then can begin monitoring once daily c. Target therapeutic heparin level by Anti Xa assay is 0.3-0.7 U/mL d. 32 General guidelines for managing anticoagulation in ECMO have been summarized and published by the Extracorporeal Life Support Organization. The anticoagulant action and side effects of heparin are dose dependent. In addition this guideline reviews treatment options for select adverse events of anticoagulation including: bleeding and heparin-induced thrombocytopenia (HIT). In addition, the Clinical Haematology department has developed guidelines to support clinician's management of warfarin and low molecular weight heparin (Clexane). The target audience for this guideline is healthcare professionals involved in the management of patients receiving heparin. Consider sending an ACT for bleeding patients to determine 3. for patients starting iv unfractionated heparin (ufh), we suggest that the initial bolus and the initial rate of the continuous infusion be weight adjusted (bolus 80 units/kg followed by 18 units/kg per h for vte; bolus 70 units/kg followed by 15 units/kg per h for cardiac or stroke patients) or use of a fixed dose (bolus 5,000 units followed by … For patients starting IV unfractionated heparin (UFH), we suggest that the initial bolus and the initial rate of the continuous infusion be weight adjusted (bolus 80 units/kg followed by 18 units/kg per h for VTE; bolus 70 units/kg followed by 15 units/kg per h for cardiac or stroke patients) or use of a fixed dose (bolus 5,000 units followed by 1,000 units/h) rather than alternative . Anticoagulation Monitoring in Left Ventricular Assist Device Patients Adam C Sieg1*, Jennifer A Gass2, Phillip Weeks2, Indranee Rajapreyar3, and Igor Gregoric4 1 University of Kentucky, Department of Pharmacy, Lexington, KY 2 Memorial Hermann - Texas Medical Center, Department of Pharmacy, Houston, TX mass index >30), the ASH guideline panel suggests using actual body weight for LMWH dose selection rather than dose selection based on a fixed maximum daily dose (i.e., capped dose) . (Fractionation produces concentrations of heparin molecules of similar sizes, as in low molecular weight heparin. As there are many assays that are used for measuring aPTT, this . Draft guidelines were revised by consensus. • Diagnosed with "heparin resistance" Anticoagulation Monitoring "Heparin Resistance" N Engl J Med. In addition to heparin and warfarin, each of the direct oral anticoagulants have different reversal mechanisms. While each medical center has their own scheme, a sample nomogram can be found in the ACCP 8 guidelines (page 7) or in this article (figure 7). Heparins are used at high dose to treat systemic thrombosis and at lower doses for thromboprophylaxis. All admitted patients should receive thromboprophylaxis unless they meet one or more of the contraindications below. Assays used to monitor heparin. The basic assays for monitoring UFH therapy are the activated partial thromboplastin time (APTT) and/or the chromogenic antifactor Xa … Prophylactic (low dose) heparin does not usually require monitoring. Methods: UW Medicine Anticoagulation Services March 2021 RECOMMENDATIONS FOR DOAC TO INTRAVENOUS HEPARIN TRANSITION This algorithm is intended as a general guideline, not a protocol, for transitioning patients taking DOACs (direct oral anticoagulants) to IV heparin. These guidelines assume the choice of anticoagulant has already been made. Guidelines on the use and monitoring of heparin. Daily monitoring of PT/INR and aPTT is recommended for patients concurrently on heparin and warfarin. 1997;157:2475-2479. Cirrhosis is a disease state that is accompanied by significant alterations in laboratory parameters, such as platelet count (PLT) and prothrombin time/international normalized ratio (PT/INR), routinely used to estimate clotting. used for heparin monitoring. To ad- The heparin anti-Xa assay is unreliable for unfractionated heparin monitoring when switching from oral factor Xa inhibitor therapy to intravenous unfractionated heparin. and/or Anti factor Xa level, however monitoring (including the test and frequency) should be according to local guidelines. The drafting group met and communicated by e-mail. acute ischemic stroke. Guidance Statement The optimal approach to heparin monitoring is unknown. SSWAHS Clinical Guidelines . Dose and monitoring. Guideline 4.1 Indications The low molecular weight heparins (LMWH), dalteparin and enoxaparin, are approved for use in Heparin infusion conversion to other anticoagulant Argatroban ts Warfarin 1. Indicated in patients with heparin-induced thrombocytopenia who require anticoagulation.. therapeutic heparin assay • Increase total 24 hour dose requirement by 10% to 20% • Divide newly calculated dose by 2 (This determines initial Q12 hour dosing) • Discontinue IV UFH and administer first SC UFH dose within 1 hour • If the monitored dosing regimen is chosen, check heparin assay at 6 hours after the Anticoagulation Forum, provides clinical guidance based on existing guidelines and consensus expert opinion where guidelines are lacking. Several coagulation assays can be used to monitor and titrate UFH. British Committee for Standards in Haematology. Authors T Baglin 1 , T W Barrowcliffe, A Cohen, M Greaves, British Committee for Standards in Haematology. The level of anticoagulation may be monitored with the APTT. Repeat laboratory monitoring: • An anti-factor Xa level ("heparin - unfractionated") will be drawn at baseline and at least every 4 hours while on ECMO according to the heparin management protocol. For this and other reasons, there is enor-mous practice variability relating to the use and dosing of heparin, monitoring heparin anticoagulation, reversal of anti-coagulation, and the use of alternative anticoagulants. 4 Unfractionated heparin is a mixture . This topic will review the general principles underlying the therapeutic use of unfractionated and LMW heparins including dosing, monitoring, and reversal of anticoagulation, as well as danaparoid (not . For Adult. Monitoring unfractionated heparin is important to achieve a therapeutic target within the ﬁ rst 24 hours and to maintain therapeutic levels thereafter. These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. Initially by intravenous injection. Heparin is a negatively charged, sulfated glycosaminoglycan polysaccharide polymer isolated from porcine intestine, where it is stored in mast-cell granules. Anticoagulation Monitoring • Anti‐factor Xa levels were markedly elevated. Purpose Low Molecular Weight Heparins (LMWH) are used for the prophylaxis and treatment of venous thromboembolism. Monitoring the therapeutic levels of heparin is critically important. mass index >30), the ASH guideline panel suggests using actual body weight for LMWH dose selection rather than dose selection based on a fixed maximum daily dose (i.e., capped dose) . For those with active clot or high risk for clotting, there must be a five day overlap of both drugs AND 2. Updated link to Octaplex Admin Policy New sub-section on Anticoagulation Guidelines Version 12 Page 5 of 59 September 2020 10.1.6 10.2 10.3 added. The easiest way for monitoring heparin is by measuring the aPTT every 4 hours and adjusting the dose accordingly. Based on this measured thrombocytopenia and coagulopathy, it has traditionally been assumed that these results convey a high risk of bleeding and, therefore . S- Initiate Heparin bolus and set infusion rate based on baseline assessment and patient information Learning Objective 2: Monitor Heparin infusion therapy according to protocol a. S- Ensure lab draws are complete according to protocol b. S- Implement adjustments to Heparin Infusion therapy c. S- Perform a focused assessment d. Guidelines- Anticoagulation: Heparin & Warfarin . Heparin is a glycosaminoglycan containing a pentasaccharide that binds to and enhances the activity of antithrombin III by inducing a conformational change, thereby inhibiting thrombin and several activated coagulation factors (XIIa, IXa, XIa, and Xa) [ 23 ]. Monitoring heparin therapy by the activated partial thrombo- Monitoring heparin therapy using activated partial thromboplastin plastin time - the eﬀect of pre-analytical conditions. Overview Heparins act by greatly enhancing antithrombin's inhibition of coagulation factors. Warfarin has many potential drug and food interactions. Rationale B leeding is the most common complication of all anticoagulants. Guideline Low Molecular Weight Heparin (LMWH) Guidelines Uncontrolled document when printed Publication date (29/07/2020) Page 1 of 4 1. In the absence of data from randomized controlled clinical trials, a number of consensus guidelines and recommendations have been published to facilitate clinical decision-making on this issue. Commonly prescribed drugs that may increase anticoagulation and INR include: acetaminophen, metronidazole, sulfamethoxalone, and omeprazole. 2006 Apr;133(1):19-34. doi: 10.1111/j.1365-2141.2005.05953.x. Since the initial guideline published by the British Committee for Standards in Haematology (BCSH; Colvin & Barrowcliffe, 1993) evidence-based guidelines on the use and monitoring of heparin have . 2) Loading dose 5000 units, alternatively (by intravenous injection) loading dose 75 units/kg, followed by (by continuous intravenous infusion) 18 units/kg/hour, alternatively (by subcutaneous injection) 15 000 units every 12 hours, laboratory monitoring essential—preferably on a daily basis, and dose adjusted accordingly. conduct of anticoagulation for CPB has not been organized into a succinct guideline. Royal College of Obstetricians and Gynaecologists. New low molecular weight heparins (LMWH) have more predictable pharmacokinetic profiles and longer duration of action than unfractionated heparin (UFH), but are much more expensive. 28, Feb 2007 Monitoring heparin. 33. III. Heparin (also described as unfractionated heparin) usually requires hospitalization for careful monitoring of the activated PTT and monitoring for potential side effects. Since the initial guideline published by the British Committee for Standards in Haematology . Heparins, including unfractionated heparin and a variety of low molecular weight (LMW) heparin products, are used extensively as anticoagulants. Guidelines on the use and monitoring of heparin T. Baglin, T. W. Barrowcliffe, A. Cohen and M Greaves for the British Committee for Standards in Haematology Department of Haematology, Addenbrookes NHS Trust, Cambridge, UK Keywords: heparin, guideline, low-molecular weight heparin. Updated link to Octaplex Admin Policy New sub-section on Br J Haematol 2006, 133, 19-34 2. guidelines for reversal of anticoagulation and management of bleeding events related to each anticoagulant medication. Thromb Haemost time - results of a multicenter trial establishing the therapeutic range 1987; 57: 226-31. Direct anti-Xa level monitoring is recommended in those with heparin resistance (see subsequent section), baseline aPTT elevation from a lupus anticoagulant or contact factor deficiency or those with markedly elevated levels of fibrinogen or factor VIII [ 24 ]. PTT may be used to monitor heparin as an alternative to anti-Xa levels in patients with hyperbilirubinemia, hemolysis, hypertriglyceridemia, or direct factor Xa inhibitor use that might interfere with anti-Xa levels. 33. Heparin Nomogram. Practices considered include guidance on selection of dosing nomograms, initial and maintenance monitoring of Wait 3 hours after discontinuation of heparin infusion to start ar gatroban infusion. Their optimal place in therapy is still under debate and is currently being investigated in clinical trials. Additional recommendations for perioperative management and outpatient treatment of individuals requiring anticoagulants are also included. As such, twice-daily DOACs (e.g., apixaban) may actually be more forgiving than once-daily agents (e.g., rivaroxaban). Guidelines on the use and monitoring of heparin. Monitoring unfractionated heparin therapy: relationship between eight anti-Xa assays and a protamine titration assay. Heparin is a highly sulfated mucopolysaccharide. This clinical practice guideline is intended to provide a standardize process for the initiation, maintenance and monitoring of intravenous unfractionated heparin used for therapeutic indications. Heparin or LMWH should be administered at initiation of the vitamin K antagonist and be continued for a minimum of five days and until the international normalized ratio (INR) is in the targeted. Low Molecular Weight Heparin Monitoring with AntiXa Levels Monitoring with AntiXa Levels Anti-Xa Activity for LMWH (LMWXA) routine monitoring is not recommended - there is no "therapeutic range" for LMWH dosing adjustments to reach a particular target range is not recommended no optimal target range is correlated with efficacy or clinical endpoints • ACTs are no longer routine. Achieve single therapeutic INR ≥ 2 prior to stopping heparin infusion. Order goal anti-Xa level (low intensity 0.3-0.5 units/mL or regular intensity 0.3-0.7 units/mL). Activated partial thromboplastin time. • Diagnosed with "heparin resistance" Anticoagulation Monitoring "Heparin Resistance" 6.1. 8 , 9 , 10 Table 2. agents. Adherence should be assessed at every visit by completing a thorough patient . 2. 1996;335:701-707. • Heparin infusion reduced to 1,500 units/hr • Hematuria resolved, no further thromboembolic or hemorrhagic sequelae. This clinical practice guideline is intended to provide a standardized process for the initiation, maintenance and monitoring of intravenous unfractionated heparin. The level of anticoagulation may be monitored with the APTT. Order as needed Re-Bolus for subtherapeutic anti-Xa, if warranted. but there is significant practice variation. Critically ill patients with COVID-19 are at increased risk for thrombotic complications which has led to an intense debate surrounding their anticoagulation management. A comparison of low-dose heparin with low-molecular-weight-heparin as prophylaxis against venous thromboembolism after major trauma. • Heparin infusion reduced to 1,500 units/hr • Hematuria resolved, no further thromboembolic or hemorrhagic sequelae. Heparin levels are measured by lab tests that check the concentration of heparin in the blood. Interim addendums will be published as required on the BCSH website ( http://www.bcshguidelines.com ). Mechanism of action of UFH Heparin is a naturally-occurring glycosaminoglycan polymer that has a physiologic anti-coagulant function. Anticoagulation guidelines for UW Medicine. Thromboembolic disease in pregnancy and the peurperium: Acute management. FDA. Point-of-Care Monitoring of Anticoagulation Therapy; Approved Guideline This document provides guidance to users and manufacturers of point-of-care coagulation devices for monitoring heparin and warfarin anticoagulant therapy, and to ensure reliable results comparable to those obtained by routine clinical laboratory testing. If the patient has not received heparin in the 30 days before the current course of heparin, the ASH guideline panel suggests monitoring the platelet count from day 4 until day 14 or until heparin is stopped, whichever occurs first, if practicable. Anticoagulation Guidelines Version 12 Page 5 of 59 September 2020 10.1.6 10.2 10.3 added. SSWAHS Clinical Guidelines While standardized dosing guidelines exist, each patient clears heparin at a slightly different rate, making dose response somewhat unpredictable. These newer agents require less monitoring than warfarin since INR does not need to be followed with these medications. Supplemental Chest Guidelines from 2016 (see Kearon, et al., under References) recommend Increase anticoagulation and INR include: acetaminophen, metronidazole, sulfamethoxalone, and pharmacokinetic properties ( Table ). 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