Low Molecular Weight Heparin (LMWH) Guidelines
All patients must have a VTE risk assessment completed on admission.
Dalteparin should be prescribed for both prophylaxis and treatment of VTE.
It is given by subcutaneous injection and is always administered as a full syringe.
It does not require routine monitoring, however, if the patient is prescribed Dalteparin for
more than 7 days the patient should have platelet counts monitored.
Before prescribing Dalteparin all patients need to have FBC and renal function
checked.
When prescribing treatment doses all patients must be weighed and the weight and date
weighed recorded on the prescription chart.
Please note specific information for
Use in renal Impairment
Patient with solid tumours: Extended treatment of symptomatic VTE and
prevention of its recurrence
Use during Pregnancy
Patients at increased risk of bleeding
Use with spinal and epidural catheters
Low Molecular Weight Heparin (LMWH) Guidelines
Page 1 of 6
Prepared by WS -Anticoagulant Pharmacist .......................................................................................... October 2012
Approved by Medicines Management Committee .................................................................................. 15th November 2012
Review Date................................................................................................................................................ November 2014
Dosing Guide
Prophylaxis
Indication
Dose
Medical prophylaxis VTE
Surgical prophylaxis VTE
Moderate risk
Surgical prophylaxis VTE
High risk e.g. Orthopaedic
surgery
5000 units once daily*
2500units once daily
5000 units once daily (in the
evening)**
Dose reduction in Renal
Impairment
No change
No change
No change
* If high risk of bleeding, < 46 kg or frail elderly or eGFR < 10ml/min consider
reducing to 2500 units daily
Treatment
Indication
Dose
Dose reduction in Renal
Impairment eGFR 20-29
ml/min/1.73m2
Treatment VTE (DVT, PE
or both)
Dose according to body
weight:-
Dose according to body
weight:-
Body
Weight (kg)
< 46
46-56
57-68
69-82
83 kg and
over
Daily dose
(units)
7500
10000
12500
15000
18000
The single daily dose should
not exceed 18,000 units**
** If BMI > 40 discuss with
haematologist as may need
dose adjustment/ Anti Xa
monitoring
Body
Weight (kg)
< 46
46-56
57-68
69-82
83 - 99 kg
> 100kg
Daily dose
(units)
5000
7500
10000
10000
12500
15000
If treatment continues for > 7
days discuss with
haematologist as may need
Anti Xa levels monitored
Use Unfractionated
heparin if eGFR < 20
ml/min/1.73m2
Continue until INR result in
range (see anticoagulant
guidelines for details)
Continue until INR result in
range (see anticoagulant
guidelines for details)
Treatment of Acute
Coronary Syndrome
See guidelines for
Fondaparinux
See guidelines for
Fondaparinux
Anticoagulation following
treatment with thrombolytic
therapy for myocardial
infarction
See guidelines for
Fondaparinux
See guidelines for
Fondaparinux
Low Molecular Weight Heparin (LMWH) Guidelines
Page 2 of 6
Prepared by WS -Anticoagulant Pharmacist .......................................................................................... October 2012
Approved by Medicines Management Committee .................................................................................. 15th November 2012
Review Date................................................................................................................................................ November 2014
Patients with solid tumours: extended treatment of symptomatic VTE
and prevention of its recurrence
For the first 30 days of treatment, patients should be dosed as above in the treatment
of VTE table.
In the case of chemotherapy-induced thrombocytopenia:
Platelet count between 50,000 and 100,000/ mm 3 - reduce daily dose of Dalteparin by
2,500 units until the platelet count recovers to ≥ 100, 000/ mm3
Platelet counts < 50,000/ mm3 - discontinue Dalteparin until platelet count recovers
above 50,000/mm3
Month 2 onwards
Dalteparin should be administered at a dose of approximately 150IU/kg once daily as
shown in the table below
Body Weight (kg)
≤ 56
57 to 68
69 to 82
83 to 98
≥ 99
Dose (IU)
7500
10000
12500
15000
18000
NB. Relevance of continuing treatment beyond 6 months will be evaluated according to
individual risk/ benefit ratio, taking into account particularly the progression of cancer.
(CLOT study only has information up to 6 months)
Low Molecular Weight Heparin (LMWH) Guidelines
Page 3 of 6
Prepared by WS -Anticoagulant Pharmacist .......................................................................................... October 2012
Approved by Medicines Management Committee .................................................................................. 15th November 2012
Review Date................................................................................................................................................ November 2014
Use in Pregnancy
Please see the trust guidelines for use of LMWH in pregnancy by using the link
below
“Guideline for the management of women at risk of, or who develop, thrombo-embolic
disease during pregnancy, birth or the puerperium.”
The administration of medications containing benzyl alcohol as a preservative to
premature neonates has been associated with fatal “Gasping Syndrome”. Dalteparin
ampoules and vials contain benzyl alcohol and as this may cross the placenta they
should not be used in pregnancy.
Dalteparin syringes do not contain preservatives and so doses should be determined using
multiples of whole syringes.
Prophylaxis in Pregnancy
Pregnant woman’s
booking in weight (kg)
< 50
50-90
91-130
131-170
> 170
Dose
2500 units daily
5000 units daily
7500 units daily *
10000 units daily *
75 units/kg/day *(rounded to the
nearest whole syringe)
*may be given in 2 divided doses
Dose reduction in
Renal impairment
No change unless
eGFR is less than
30ml/minute
If the eGFR is less than 30ml/minute contact haematologist for advice
Discuss with the haematologist for treatment of VTE in Pregnancy
Treatment of VTE (DVT/PE) in Pregnancy
Weight(kg)
AM Dose (units)
PM Dose (units)
<50
5000
5000
50-64
7500
5000
65-79
7500
7500
80-94
10000
7500
95-109
10000
10000
110-124
12500
10000
125-139
12500
12500
140-154
15000
12500
155-169
15000
15000
If the eGFR is less than 30ml/minute contact haematologist for advice.
Check anti Xa levels - Monitoring may be required in extreme body weight (prepregnancy weight <50kg or >90 kg), renal impairment and recurrent VTE on therapeutic
LMWH.
For monitoring of anti-Xa level: Sample should be taken 4 hours after the subcutaneous
dose of dalteparin. The therapeutic range is 0.5 – 1.2 units/ml for therapeutic dose of
dalteparin
Low Molecular Weight Heparin (LMWH) Guidelines
Page 4 of 6
Prepared by WS -Anticoagulant Pharmacist .......................................................................................... October 2012
Approved by Medicines Management Committee .................................................................................. 15th November 2012
Review Date................................................................................................................................................ November 2014
For Patients with an increased risk in bleeding:
It is recommended that dalteparin be administered twice a day at a dose of 100 units/kg.
Please discuss with the haematologist and always prescribe doses as whole syringes.
LMWH and the use of spinal and epidural catheters
Spinal anaesthetics should not be undertaken, and epidural catheters should not be sited
or removed, less than 12 hours after a prophylactic dose of LMWH or less than 24
hours after a therapeutic dose of LMWH.
LMWH can safely be given 2 to 4 hours after siting of a block or removal of an epidural.
Length of Treatment
See individual guidelines for the length of treatment needed for specific
conditions eg:
Orthopaedic Directorate Guidelines for Venous Thrombo-embolism (VTE) –
Prophylaxis in High Risk Orthopaedic Surgery
Where there are no guidelines eg:
Surgical bariatric patients require 7 days LMWH on discharge.
High risk Gynaecology Surgery – discuss with consultant
Discharging patients on Dalteparin
Include the following information on the discharge letter:
Dose
Duration
o start date and course length for all prophylactic courses must be
stated clearly
o For treatment doses, when the patient is being transferred to management
with warfarin, treatment should be continued until INR result has been in
range for at least 24 hours ie 2 INR results need to be in range before
discontinuing the LMWH
Monitoring requirements: State what tests are needed and when they should be
done e.g. check platelets seven days after initiation of therapy and the subsequent
frequency and type of monitoring
If the patient is self administrating then prescribe a sharps bin
Supply sufficient quantity for the course
Low Molecular Weight Heparin (LMWH) Guidelines
Page 5 of 6
Prepared by WS -Anticoagulant Pharmacist .......................................................................................... October 2012
Approved by Medicines Management Committee .................................................................................. 15th November 2012
Review Date................................................................................................................................................ November 2014
Dalteparin (Fragmin®) Dose Administration
SURGICAL - MODERATE RISK
2500 units DAILY
PROPHYLAXIS BLUE
SURGICAL - HIGH RISK
MEDICAL
5000 units DAILY
ORANGE
SEE LOW MOLECULAR WEIGHT HEPARIN GUIDELINES FOR: (search for dalteparin [in power search] from intranet homepage)
Dose in renal impairment (If eGFR < 30ml/min/1.73m2 )
Use in pregnancy
For timings of doses
For further advice contact Pharmacy
TREATMENT DOSES
for VTE (DVT/PE)
Dose according
to body weight
Give the dose
once a day
Do not give more
than 18,000 units
daily
Body Weight
(kg)
Daily dose
(units)
< 46
7,500
46-56
10,000
57-68
12,500
69-82
15,000
83 kg and
over
18,000
Syringe – dose and colour
GREEN
RED
BROWN
PURPLE
GREYBLUE
Low Molecular Weight Heparin (LMWH) Guidelines
Page 6 of 6
Prepared by WS -Anticoagulant Pharmacist .......................................................................................... October 2012
Approved by Medicines Management Committee .................................................................................. 15th November 2012
Review Date ................................................................................................................................................ November 2014