Parenteral anticoagulants for the treatment of HIT
| Agent . | Initial dosing . | Monitoring . | Clearance (half-life) . |
|---|---|---|---|
| Direct thrombin inhibitors | |||
| Argatroban | Bolus | Adjust to aPTT of 1.5-3.0 times patient baseline* | Hepatobiliary (40-50 minutes) |
| None | |||
| Continuous infusion | |||
| Normal organ function → 2 μg/kg per minute | |||
| Liver dysfunction (total serum bilirubin > 1.5 mg/dL), heart failure, postcardiac surgery, anasarca → 0.5-1.2 μg/kg per minute | |||
| Lepirudin | Bolus | Adjust to aPTT of 1.5-2.0 times patient baseline* | Renal (80 minutes) |
| 0.2 mg/kg (only for life- or limb-threatening thrombosis) | |||
| Continuous infusion | |||
| Cr < 1.0 mg/dL → 0.10 mg/kg per hour | |||
| Cr 1.0-1.6 mg/dL → 0.05 mg/kg per hour | |||
| Cr 1.6-4.5 mg/dL → 0.01 mg/kg per hour | |||
| Cr > 4.5 mg/dL → 0.005 mg/kg per hour | |||
| Bivalirudin† | Bolus | Adjust to aPTT of 1.5-2.5 times patient baseline* | Enzymatic and renal (25 minutes) |
| None | |||
| Continuous infusion | |||
| Normal organ function → 0.15 mg/kg per hour | |||
| Renal or hepatic dysfunction → dose reduction may be appropriate | |||
| Desirudin† | 15 mg or 30 mg subcutaneously every 12 hours | Probably not necessary; plasma levels of drug correlate with aPTT | Renal (2 hours) |
| Indirect FXa inhibitors | |||
| Danaparoid | Bolus | Adjust to anti-FXa of 0.5-0.8 U/mL | Renal (24 hours) |
| < 60 kg → 1500 U | |||
| 60-75 kg → 2250 U | |||
| 75-90 kg → 3000 U | |||
| > 90 kg → 3750 U | |||
| Accelerated initial infusion | |||
| 400 U/hour × 4 hours, then 300 U/hour × 4 hours | |||
| Maintenance infusion | |||
| Normal renal function → 200 U/hour | |||
| Renal insufficiency → 150 U/hour | |||
| Fondaparinux† | < 50 kg → 5 mg subcutaneously daily | None‡ | Renal (17-20 hours) |
| 50-100 kg → 7.5 mg subcutaneously daily | |||
| > 100 kg → 10 mg subcutaneously daily | |||
| ClCr 30-50 mL/min → use caution | |||
| ClCr < 30 mL/min → contraindicated | |||
| Agent . | Initial dosing . | Monitoring . | Clearance (half-life) . |
|---|---|---|---|
| Direct thrombin inhibitors | |||
| Argatroban | Bolus | Adjust to aPTT of 1.5-3.0 times patient baseline* | Hepatobiliary (40-50 minutes) |
| None | |||
| Continuous infusion | |||
| Normal organ function → 2 μg/kg per minute | |||
| Liver dysfunction (total serum bilirubin > 1.5 mg/dL), heart failure, postcardiac surgery, anasarca → 0.5-1.2 μg/kg per minute | |||
| Lepirudin | Bolus | Adjust to aPTT of 1.5-2.0 times patient baseline* | Renal (80 minutes) |
| 0.2 mg/kg (only for life- or limb-threatening thrombosis) | |||
| Continuous infusion | |||
| Cr < 1.0 mg/dL → 0.10 mg/kg per hour | |||
| Cr 1.0-1.6 mg/dL → 0.05 mg/kg per hour | |||
| Cr 1.6-4.5 mg/dL → 0.01 mg/kg per hour | |||
| Cr > 4.5 mg/dL → 0.005 mg/kg per hour | |||
| Bivalirudin† | Bolus | Adjust to aPTT of 1.5-2.5 times patient baseline* | Enzymatic and renal (25 minutes) |
| None | |||
| Continuous infusion | |||
| Normal organ function → 0.15 mg/kg per hour | |||
| Renal or hepatic dysfunction → dose reduction may be appropriate | |||
| Desirudin† | 15 mg or 30 mg subcutaneously every 12 hours | Probably not necessary; plasma levels of drug correlate with aPTT | Renal (2 hours) |
| Indirect FXa inhibitors | |||
| Danaparoid | Bolus | Adjust to anti-FXa of 0.5-0.8 U/mL | Renal (24 hours) |
| < 60 kg → 1500 U | |||
| 60-75 kg → 2250 U | |||
| 75-90 kg → 3000 U | |||
| > 90 kg → 3750 U | |||
| Accelerated initial infusion | |||
| 400 U/hour × 4 hours, then 300 U/hour × 4 hours | |||
| Maintenance infusion | |||
| Normal renal function → 200 U/hour | |||
| Renal insufficiency → 150 U/hour | |||
| Fondaparinux† | < 50 kg → 5 mg subcutaneously daily | None‡ | Renal (17-20 hours) |
| 50-100 kg → 7.5 mg subcutaneously daily | |||
| > 100 kg → 10 mg subcutaneously daily | |||
| ClCr 30-50 mL/min → use caution | |||
| ClCr < 30 mL/min → contraindicated | |||