VTE/Stroke Drugs and Doses

UFH — prophylaxis

5000 units SC every 12 or 8 hours 

Enoxaparin (Lovenox)—Prophylaxis

Medically ill: 40 mg SC every 24 hours
surgically ill: 30 or 40mg Q12-24
IF CrCl is less than 30 dose 30mg SC every 24 hours 

Dalteparin (Fragmin) —Prophylaxis

5000 units SC every 24 hours 

Fondaparinux (Arixtra)—Prophylaxis

2.5 mg SC every 24 (ONLY if the pt is greater than 50kg AND a CrCl greater than 30) 

Apixaban (Eliquis)—Prophylaxis

SURGICAL ONLY — 2.5 mg PO BID 12-35 days 

Rivaroxaban (Xarelto)—Prophylaxis

BOTH medically ill/surgical — 10 mg PO daily for 31-39 days

CI if CrCl is less than 15 

Dabigatran (Pradaxa)—Prophylaxis

SURGICAL ONLY— 110mg on day 1 post surgery then 220 mg PO daily for 28-35 days 

Warfarin—Prophylaxis

SURGICAL ONLY—dose to maintain INR 2-3 

UFH —Treatment

80-100 units/kg (max 10,00units) followed by 17-20 units/kg IV infusion 

Enoxaparin (Lovenox)—Treatment

1 mg/kg SC Q12 hours

OR

1.5 mg/kg SC Q24 hours

If CrCl is less than 30 adjust dose to 1 mg/kg Q24 hours

Dalteparin (Fragmin)—Treatment

200 units/kg SC Q24 hours

OR

100 units/kg SC Q12 hours 

Fondaparinux (Arixtra) —Treatment

IF <50kg: 5 mg SC Q24 hours 

IF 50-100 kg: 7.5mg SC Q24 hours 

IF >100kg: 10 mg SC Q24 hour 

IF CrCl <30 —CI

Apixaban(Eliquis) —Treatment

start at 10 mg BID x7days for initiation,

then 5 mg BID for treatment phase.

Extended phase (after 6 mo treatment) 2.5 mg BID Start as mono therpay during initiation phase 

Rivaroxaban (Xarleto)—Treatment

15mg (initiation) PO BID X21 day then

20 mg PO daily (WITH FOOD) (treatment)

Extended phase: 10 mg QD W/WO Food wont use if CrCl drops <15mL/min

Edoxaban (Savaysa)—Treatment

MUST have a parenteral anticoagulant for at least 5 days before switching to this for treatment phase.

60 mg QD

if weight less than 60 kg, if CrCl 15-50, or on P-gp inhibitors switch to 30 mg

Don't use if CrCl is under 15.

Dabigatran/Pradaxa—Treatment

must have parental anticoag 5 days before we switch to drug

150 mg PO BID (tx phase– w or w/o food).

If CrCl is <30 mL/min DO NOT USE

if extended therapy is chosen it's the same dose

Warfarin—Treatment

Dose it to maintain INR 2-3, Need overlapping parenteral anticoagulant (take in addition to Warfarin) for at least 5 days and until INR is therapeutic for 2 consecutive readings (>24 hrs)

IV Alteplase—Thrombolytic therapy

Dose: alteplase 100 mg infused via peripheral vein over 2 hours

50 mg dosing regimen is used in patients who weigh < 65 kg

Activated charcoal

50g admin to pts presenting within 2-4 hours of ingestion (ALL EXCEPT WARFARIN)

Hemodialysis

Dabigatran

KCentra (4-Factor prothrombin concentrate)

INR 2-<4: 25 units/kg (max 2,500 units)

INR 4-5: 35 units/kg (max 3,500 units)

INR>6: 50 units/kg (max 5,000 units)

Novoseven RT

Fondaparinux reversal

Proamine

For UFH:Dose is 1mg for every 100 Units of UFH

For LMWH: Dose is 1mg for every 1 mg of enoxaparin, or 1 mg for every 100 antifactor-Xa

Phytonadione (Vitamin K)

Reverses warfarin (Dose 2.5-10mg) 

Apixaban (Eliquis)—non-valvular Afib

Apixaban 5 mg PO every 12 hours

◼ Dose adjustments:

◼ 2.5 mg PO every 12 hours if at least 2 of the following criteria:

➢ Age ≥ 80 years

➢ Weight ≤ 60 kg

➢ Scr ≥ 1.5 mg/dL

◼ 2.5 mg PO every 12 hours if CrCl < 30 mL/min

Rivaroxaban (Xarleto) —non-valvular Afib

◼ 20 mg PO daily if CrCl > 50 mL/min

◼ 15 mg PO daily if CrCl ≤ 50 mL/min

Dabigatran(Pradaxa)—non-valvular Afib

◼ 150 mg PO every 12 hours if CrCl > 30 mL/min

◼ 75 mg PO every 12 hours if CrCl 15-30 mL/min

Edoxaban(Savaysa)—non-valvular Afib

◼ 60 mg PO daily if CrCl > 50 to ≤ 95 mL/min 

◼ 30 mg PO daily if CrCl is 15-50 mL/min

Warfarin—non-valvular Afib

Starting dose 5 mg in most pts; lower doses are used in sensitive patients (1-3 mg)

Alteplase (tPA or rtPA)—Stroke treatment

0.9 mg/kg IV infused over 60 min with 10% of the dose given as an initial bolus over 1 min

Total max dose is 90 mg

Tenecteplase—Stroke treatment

0.25 mg/kg as a single IV bolus –Total max dose is 25 mg 

DAPT —Clopidogrel + ASA

(with a loading dose of clopidogrel)

Combination is for 21 days, followed by clopidogrel or ASA for 90 days

DAPT—Ticagrelor + ASA

(with a loading dose of ticagrelor)

Combination is for: Duration 30 days OR Duration 30 days followed by ticagrelor for 90 days

VTE prophylaxis in stroke —UFH

UFH 5000 units SubQ TID 

VTE prophylaxis in stroke— Enoxaparin

Enoxaparin 40 mg SubQ daily