Anticoagulants

Drug Forms Drug Indication Dosing/ Adjustments Adverse Effects/

Class Monitoring
Warfarin Tablet: 1, Vitamin K DVT Prophylaxis due to: 2-5mg QD initial or 10mg QD Bleeding,
(Coumadin) 2, 2.5, 3, Antagonist o Valvular/non-valvular x2days (healthy) bruising,
4, 5, 6, AF *No dose adjustments in hypersensitivity,
7.5, 10 o Mechanical valves renal/hepatic impairment skin necrosis
mg o Myocardial infarction *Monitor INR, PT,
Treatment of VTE hct
Apixaban Tablet: Factor Xa Treatment of DVT/PE 10mg BID x7d5mg BID x6mo Bleeding, nausea,
(Eliquis) 2.5, 5mg Inhibitor o 2.5mg BID x6mo for anemia
recurrence *Monitor CrCl,
DVT Prophylaxis in: 5mg BID or 2.5mg BID if two of BUN, Scr, CBC,
o Non-valvular AF following: LFTs
o ≥80y, ≤60kg, SCr
≥1.5mg/dL
o Post-op hip/knee 2.5mg BID x 35d(hip) or
surgery 12d(knee)
*Avoid use in severe hepatic
impairment
Rivaroxaban Tablet: Factor Xa Treatment of DVT/PE 15mg BID x21d20mg QD x3- Bleeding,
(Xarelto) 10,15, Inhibitor 6mo dizziness,
20mg o 10mg QD insomnia,
o CrCl<30mL/min: Avoid use abdominal pain
DVT prophylaxis in: 20mg QD *Monitor BUN,
o Non-valvular AF o CrCl15-50mL/min: 15mg QD CrCl, SCr, LFTs
(Canadian labeling)
o CrCl<30mL/min: Avoid use
(Beers)
o Post-op hip/knee 10mg QD x35d(hip) or
surgery x12d(knee)
o CrCl<30mL/min: Avoid use
*Avoid use in BMI>40kg/m2 or
>120k
*Avoid use in moderate to severe
hepatic impairment
Edoxaban Tablet: Factor Xa Treatment of DVT/PE 60mg QD after 5-10d of initial Bleeding, skin
(Savaysa) 15, 30, Inhibitor parenteral anticoagulant rash, GI
60mg o If ≤60kg:30mg QD hemorrhage,
o CrCl 15-50mL/min: 30mg abnormal LFTs
QD *Monitor BUN,
o CrCl <15mL/min: Avoid use CrCl/SCr, LFT

DVT prophylaxis in: 60mg QD

o Non-valvular AF o CrCl>95mL/min: Avoid use
o CrCl 15-50mL/min: 30mg
QD
o CrCl<15mL/min: Avoid use
*Avoid use in moderate to severe
impairment
Fondaparinux SQ Factor Xa Treatment of DVT/PE <50kg: 5mg QD Bleeding,
(Arixtra) solution: Inhibitor 50-100kg: 7.5mg QD hypotension,
2.5mg/0. >100kg: 10mg QD insomnia,
5mL, o Bridge with warfarin until hypokalemia,
5mg/0.4 INR≥2 at least 24hrs increased
 mL, DVT prophylaxis in:
7.5mg/0. o Hip/knee replacement
6mL, o Abdominal surgery
10mg/0.8
mL o STEMI
o NSTEMI/UA
Enoxaparin LMWH Treatment of DVT
(Lovenox)
DVT prophylaxis in:
o Hip/knee replacement
o Abdominal surgery
o Acute illness with
restricted mobility and
risk (>40y, obesity,
general anesthesia
>30min, malignancy, hx
of DVT/PE)
PCI anticoagulation
STEMI
≥50kg: 2.5mg QD ALT/AST,
o <50kg: Avoid use thrombocytopeni
o If hx of HIT: 2.5mg QD a
*Monitor: CBC,
2.5mg IV once 2.5mg SQ QD for platelets, SCr, Anti-
duration of Xa
hospitalization/revascularization
(up to 8 days)
2.5mg SQ QD for duration of
hospitalization/until PCI
*CrCl 30-50 mL/min: Use caution
*CrCl <30mL/min: Contraindicated
*No hepatic adjustments
1mg/kg q12h or 1.5mg/kg QD Bleeding, anemia,
o In obesity: BID dosing peripheral edema,
preferred (use ABW) nausea, increased
o In pregnant: 1mg/kg q12h ALT/AST, fever,
o Bridge with warfarin until thrombocytopeni
INR≥2 at least 24hrs a
*CrCl <30mL/min: 1mg/kg QD *Monitor:
30mg Q12h x10d or until bridged Platelets, occult
to warfarin blood, anti-Xa (if
*CrCl<30mL/min: 30mg QD >144kg, use anti-
40mg QD (usually 7-10d) Xa to adjust dose)
40mg QD (usually 6-11d)
*In obese, consider increase by 30%
for prophylaxis
0.5-0.75mg/kg IV bolus initial
<75y.o: 30mg IV bolus1mg/kg
SQ Q12h
*CrCl<30: 30mg IV bolus1mg/kg
SQ QD
≥75y.o: 0.75mg/kg Q12h (no IV
bolus)
*CrCl<30mL/min: 1mg/kg SQ QD

NSTEMI 1mg/kg q12h with ASA until

PCI/duration of hospitalization
Mechanical heart valve 1mg/kg SQ Q12h
bridging
*No hepatic adjustments
Dalteparin SQ LMWH DVT Treatment 200U/kg QD or 100U/kg BID Bleeding,
(Fragmin) Solution: thrombocytopeni
DVT prophylaxis in: Low-mod risk: 2,500U SQ QD x5-
25,000U/ a, increased
o Abdominal surgery at 10d
mL, ALT/ASTs
risk (>40y, obese, High risk: 5,000U SQ QD x5-10d
95,000U/ *Monitor CBC,
malignancy, hx of
3.8mL, platelets, anti-Xa
DVT/PE,
10,000U/ levels (use to
anesthesia>30min)
mL, 2,500 adjust dose if
U/0.2mL, >190kg)
5,000U/0.
2mL, 2,500U 4-8hrs post-op5,000U
7,500U/0. o Hip-replacement QD OR
3mL,
 12,500U/ o 2,500U 2hrs pre-op2,500U
0.5mL, 4-8hrs post-op5,000U QD
15,000U/ OR
0.6mL, o 5,000U 10-14 hrs pre-op4-
18,000U/ 8hrs post-op5,000U QD
0.72mL o Acute illness with 5,000 SQ QD
immobility
NSTEMI/UA 120U/kg (max 10,000U) Q12h
with ASA
*Use ABW in obese (max 10,000U)
Mechanical heart valve 100U/kg Q12h
bridging
General Surgery with VTE o 2,500U SQ 1-2hrs pre-op
risk factors 2,500-5,000U QAM OR
o May give 5,000U pre-
op5,000UQPM post-op if
risk factors (~5-7 days)
*No renal/hepatic adjustments
UFH Heparin IV Heparin Treatment of DVT/PE o 80U/kg IV push(or Thrombocytopeni
Solutions anti- 5,000U)continuous infusion a, chest pain,
coagulant of 18U/kg/hr OR shock, headache,
o 333U/kg q12h increased LFTs
DVT Prophylaxis in: 5,000U SQ q8-12h *Monitor: Hgb, hct,
o Orthopedic surgery aPTT, anti-Xa,
STEMI/NSTEMI 60U/kg IV bolus12U/kg/hr IV ACT, platelets(q2-
continuous (up to 8 d) 3days on days 4-14
Cardiopulmonary bypass 300-400U/kg IV pre-op of therapy)

PCI 70-100U/kg IV bolus (no

GP2b/3a) OR
50-70U/kg IV bolus (with
GP2b/3a)
Intermittent 10,000U IV50-70U/kg q4-6h
anticoagulation
*No renal/hepatic adjustments
Bivalirudin IV Direct NSTEMI with early invasive o 0.75mg/kg Bleeding,
(Angiomax) solution, Thrombin or STEMI with PCI bolus1.75mg/kg/hr (if hypotension,
reconstit Inhibitor during PCI) nausea, pain,
uted: o 0.1mg/kg headache,
250mg bolus0.25mg/kg/hr (if prior hypertension,
to PCI or diagnostic insomnia
angiography)as stated above *Monitor ACT,
aPTT
PCI o 0.75mg/kg IV bolus pre-
op1.75mg/kg/hr during
PCI0.3mg/kg prn to ACT 5
o May continue at 1.75mg/kg/hr
up to 4hrs post-op
*CrCl<30mL/min: decrease infusion
rate to 1mg/kg/hr
*Dialysis: Decrease infusion rate to
0.25mg/kg/hr
HIT IV 0.15-0.2mg/kg/hr to aPTT 1.5-
2.5x baseline
*CrCl>60mL/min: 0.13mg/kg/hr
*CrCl 30-60mL/min: 0.08-
 0.1mg/kg/hr
*CrCl<30mL/min:0.04-
0.05mg/kg/hr
*IHD: 0.07mg/kg/hr
*CVVH/CVVHDF: 0.03-
0.07mg/kg/hr

*No hepatic adjustments

Argatroban IV Direct HIT 2mcg/kg/min initialadjust to Bleeding, chest
(Acova) solution: Thrombin aPTT 1.5-3x baseline (max pain, hypotension,
125mg/1 Inhibitor 10mcg/kg/min) vasodilation,
25mL, *Mod-severe hepatic impairment: cardiac arrest,
250mg/2 continuous IV infusion: V.tach, headache
50mL, 0.5mcg/kg/min *Monitor hgb, hct,
250mg/2. PCI o Initial 25mcg/kg/min infusion aPTT(for HIT),
5mL; and 350mcg/kg bolus (over 3- ACT(for PCI)
50mg/50 5min) to ACT>300sec
mL, o If ACT<300sec: 150mcg/kg
250mg/2. bolus and increase to
5mL 30mcg/kg/min
o If ACT >450sec: Decrease to
15mcg/kg/min
*Avoid use in significant hepatic
impairment or ALT/AST ≥3xULN
*No renal adjustments

Dabigatran Capsules Direct DVT/PE Treatment 150mg BID (after 5-10d Bleeding,
(Pradaxa) : 75, 110, Thrombin parenteral anticoagulation) dyspepsia,
150mg Inhibitor *CrCl<50mL/min +P=gp inhibitors: abdominal pain,
Avoid use gastritis
DVT Prophylaxis in: 150mg BID *Monitor CBC,
o Non-valvular AF *CrCl 30-50mL/min + dronedarone BUN, CrCl, SCr
or oral ketoconazole: 75mg BID
*CrCl 15-30mL/min: 75mg BID;
Avoid if used with concomitant P-gp
inhibitor
*General recommendation to avoid
useCrCl<30mL/min
o Hip/Knee replacement o 110mg 1-4hrs after
surgery220mg QD (10-
35d)
o May give 220mg x1 post-op
(knee)
*No hepatic adjustments
*AF=Atrial Fibrillation
*LMWH= Low Molecular Weight Heparin