Dalteparin (Fragmin) Anticoagulant+ Low-Molecular-Weight Heparin: Action and Uses

  Dalteparin (Fragmin) Anticoagulant

Func. Class: Anticoagulant

Chem. Class: Low-Molecular-Weight Heparin.

ACTION

• Inhibits factor Xa/IIa (thrombin), resulting in anticoagulation.

USES

• Unstable angina/non-Q-wave MI, prevention and treatment of deep venous thrombosis I'm abdominal surgery, hip replacement or in those with restricted mobility during acute illness, pulmonary embolism.
• UNLABELED USES: VTE prophylaxis in gynecologic surgery.

CONTRAINDICATIONS

• Hypersensitivity to this product or heparin, active major bleeding, hemophilia, leukemia with bleeding, thrombocytopenic purpura, cerebrovascular hemorrhage, cerebral aneurysm, dalteparin induced thrombocytopenia.

PRECAUTIONS

• Hypersensitivity to benzyl alcohol, pregnancy, breastfeeding, children, recent childbirth, geriatric patients, hepatic disease, severe renal disease, acute nephritis, uncontrolled hypertension; recent brain spine eye surgery; hemorrhagic stroke

BLACK BOX ALERT

• Epidural/spinal anaesthesia, lumbar puncture

DOSAGE AND ROUTES

DVT/Pulmonary embolism (cancer-associated venous thrombosis)

• Adult: Subcut 200 units/kg daily during 1st month ( maximum single dose 18,000 units), then 150 units/kg daily for month 2-6, use prefilled syringe that is closest to calculated dose; if platelets are 50,000-100,000/mm3, reduce dose by 2500 units until platelets more than 100,000 mm3; if platelets less than 50,000/mm3 discontinue until more than 50,000/mm3.

Hip Replacement surgery/DVT Prophylaxis.

• Adults: Subcut 2500 units 2 hr before surgery and 2nd dose in the evening on the day of surgery ( 6-8 hr postop), then 5000 units Subcut 1st postop day and daily 5-10 days.

Unstable angina/non-Q-wave MI

• Adult: Subcut 120 units/kg q12hr × 5-8 days, max 10,000 units q12hr × 5-8 days with concurrent aspirin: continue until stable.

DVT, prophylaxis for abdominal surgery

• Adult: Subcut 2500 units 1-2 hr before surgery: repeat daily × 5-10 days: more than 3400 units should be used for high-risk patients.

ADMINISTRATION

• Cannot be used interchangeably (unit for unit) with unfractionated heparin or other LMWHs
• Do not give IM or IV product route; approved is Subcut only; do not mix with other injection or solution
• Have patient sit or lie down; Subcut inj maybe 2 inches from umbilicus in a U-shape, upper outer side of thigh, or upper outer quadrangle of the buttocks; rotate inj sitees.
• Change inj site daily; use at same time of day.

SIDE EFFECTS

• Intracranial bleeding
• Thrombocytopenia
• DIC
• Skin necrosis
• Hypersensitivity
• hemorrhage
• anaphylaxis

PHARMACOKINETICS

• 87% absorbed, excreted by kidneys, elimination half-life 2-2.3 hr, peak 2-4 hr onset 1-2 hr, duration up to 24 hr.

INTERACTIONS

• Increase bleeding risk-aspirin, oral anticoagulants, platelet inhibitors, NSAIDs, salicylates, thrombolytics.

DRUG/LAB TEST

• Increase: AST, ALT
• Decrease: Platelets

NURSING CONSIDERATIONS

• Blood studies- (Hct/Hgb, CBC platelets, anti-Xa) during treatment because of bleeding can occur.
• Bleeding- Bleeding gums, petechiae, ecchymosis, malena, hematuria, epistaxis, decrease in Hct, B/P may indicate bleeding, possible hemorrhage; notify prescriber immediately; product should be discontinued.
• Epidural spinal anaesthesia- neurological impairment may occur frequently when neuraxial anaesthesia has been used; spinal/epidural hematomas may occur, with paralysis; numbness in lower extremities; back pain; notify prescriber immediately; those at greatest risk are those taking products that cause increased bleeding risk.
• Hypersensitivity: fever, skin rash, urticaria; 
• Pregnancy/breastfeeding: no well-controlled studies; use only if clearly needed; LMWH does not cross the placenta; benefits and risk must be weighed with provider; if used, discontinue 24 hr before induction or cesarean delivery; use of multidose vials containing benzyl alcohol is contraindicated; use caution in breastfeeding.

TREATMENT OF OVERDOSE

• Protamine sulfate 1% given IV; 1 mg  protamine/100 anti-Xa international units of dalteparin given.