Heparin and Warfarin - Sydney South West Area Health Service

Sydney South West Area Health Service
Guideline No: SSW_GL2007_010
Date issued: November 2007
• Heparin related thrombocytopenia and thrombosis is an uncommon but
potentially serious complication of heparin therapy, requiring urgent review
of anticoagulation therapy and consultation with Senior Medical Staff (see
below).
2.6 Monitoring
• Blood should be taken 4 hours (3-5 hours) after a dose of Enoxaparin for
anti-Xa levels.
• For twice daily dosing, the therapeutic range is 0.6 - 1.0 IU/ml.
• For once daily dosing, the peak anti-Xa level should be 1-2 IU/ml (there is
less literature on once daily dosing compared to twice daily dosing).
• A full blood count should be checked second daily on inpatients on LMWH
therapy, to exclude heparin thrombocytopenia and a fall in haemoglobin to
suggest bleeding. In patients receiving extended LMHW heparin therapy
as an outpatient (e.g. anticoagulation during pregnancy), it is reasonable to
check a full blood count weekly for three weeks and then monthly.
• The possibility of a retroperitoneal bleed should be considered in the
absence of another identified cause of pain in the back, leg, or abdomen.
A full blood count should be performed and reviewed as soon as possible,
as well as urgent medical assessment and imaging of the abdomen.
• Where the therapeutic intention is anticoagulation for venous
thromboembolism, non-steroidal anti-inflammatory drugs (NSAIDs) should
be ceased to reduce the risk of bleeding.
Reference
Hirsh J & Raschke R. The Seventh ACCP Conference on antithrombotic and
thrombolytic therapy. Chest. 2004;126:188S-203S
The Australasian Creatinine Consensus Working Group. Chronic kidney disease
and automatic reporting of estimated glomerular filtration rate: a position
statement. Med J Aust 2005; 183: 138-141.
2.7 Charts for estimating GFR:
Normal Renal Function: Calculated Creatinine Clearance (eCl CR ) > 60
ml/minute
1 mg/kg twice daily
Moderate Renal Impairment: eCl CR = 30 – 60 L/min
1 mg/kg twice daily. Check peak (4 hours after a dose) ant-Xa level day 2
and day 3 of therapy, and every second day after that until stable.
Severe Renal Impairment: eCl CR < 30mL/min
1 mg/kg daily. Check peak (4 hours after a dose) ant-Xa level day 2 and
day 3 of therapy, and every second day after that until stable.
Compliance with this guideline is recommended Page 8 of 24