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Low Molecular Weight HeparinAka: LMW Heparin, Danaparoid, Orgaran, Tinzaparin, Innohep, Enoxaparin, Lovenox, Ardeparin, Normiflo, Dalteparin, Fragmin

Indications
1. Deep Vein Thrombosis Treatment
2. Deep Vein Thrombosis Prophylaxis
  1. General Surgery
  2. Orthopedic Surgery (Hip, Knee)
Contraindications (Indications for standard Heparin)
1. Previous Deep Vein Thrombosis history
  1. Ipsilateral DVT
  2. Two or more DVTs
  3. Any Venous Thromboembolism
2. High risk lesion (e.g. Iliofemoral DVT)
3. Pregnancy
4. Renal Insufficiency (Creatinine Clearance <30 due to risk of dose stacking and bleeding risk)
5. Morbidly obese patients (consider Unfractionated Heparin where BMI>40-45 kg/m2)
6. Hepatic Insufficiency
7. Active bleeding
8. Surgery in prior 5-7 days (However see below)
9. Hypercoagulable state
10. Inability to undergo outpatient treatment
11. Noncompliance
12. Thrombocytopenia
13. Coagulopathy
14. Active Peptic Ulcer Disease
Efficacy: Unstable Angina and Myocardial Infarction
1. Significantly better outcomes than standard Heparin
  1. Randomized trial (n=3171)
  2. Lower endpoint (death, Myocardial Infarction, Angina)
    1. 14 days (16.6 vs 19.8%)
    2. 20 days (19.8 vs 23.3%)
  3. Fewer revascularization procedures (27 vs 32.2%)
2. Reference
  1. Cohen (1997) N Engl J Med 337:447
Efficacy
1. Comparable efficacy to Heparin in DVT
2. References
  1. Hull (2000) Arch Intern Med 160:229
  2. Merli (2001) Ann Intern Med 134:191
Advantages: LMWH over Unfractionated Heparin
1. Rarely causes Heparin Induced Thrombocytopenia
2. Does not cause paradoxical thrombotic events
3. Results in fewer bleeding complications
4. References
  1. Warkentin (1995) N Engl J Med 332:1330
  2. (1995) Arch Intern Med 155:601
Dosing
1. General
  1. Prophylaxis: Consider increasing the dose by 25% when BMI >40 kg/m2
  2. Treatment: Dose should be based on total body weight (even in obese patients)
  3. Exception: Fragmin has a maximum dose (unlike other LMWH agents)
2. Deep Vein Thrombosis Treatment
  1. Enoxaparin (Lovenox)
    1. Twice daily dosing: 1 mg/kg SQ bid
    2. Once daily dosing: 1.5 mg/kg SQ qd (not for home)
    3. Available in 30 mg vials
  2. Tinzaparin (Innohep)
    1. Dose: 175 anti-Xa IU per kg daily
    2. Dose (ml): (weight in kg) x 0.00875 ml/kg daily
3. Deep Vein Thrombosis Prophylaxis
  1. Ardeparin (Normiflo)
    1. Initial: 50 U/kg SQ following surgery
    2. Later: bid for 14 days or until ambulatory
  2. Dalteparin (Fragmin)
    1. Low risk
      1. Initial: 2500 IU SQ 1-2 hours before surgery
      2. Later: 2500 IU qd for 5-10 days
    2. High risk
      1. Initial: 5000 IU SQ the evening before surgery
      2. Later: 5000 IU qd for 5-10 days
  3. Danaparoid (Orgaran)
    1. Initial: 750 U SQ 1-4 hours before surgery
    2. Later: then 750 U SQ q12h for 7-10 days
  4. Enoxaparin (Lovenox)
    1. Initial: 30 mg SQ q12h OR 40 mg QD for 7-10 days
  5. Tinzaparin (Innohep)
    1. Innohep 3500 IU SQ daily
Precautions
1. Severe renal insufficiency
  1. Unpredictable dose response to LMWH
2. Reversal
  1. Less responsive to protamine compared with Heparin

Orgaran (C0163842)
Concepts	Organic Chemical (T109) , Pharmacologic Substance (T121)
MSH	C035838
English	Orgaran
Sources	MSH, NCI, RXNORM Derived from the NIH UMLS (Unified Medical Language System)

Enoxaparin (C0206460)
Definition (MSH)	Low-molecular-weight fragment of heparin, having a 4-enopyranosuronate sodium structure at the non-reducing end of the chain. It is prepared by depolymerization of the benzylic ester of porcine mucosal heparin. Therapeutically, it is used as an antithrombotic agent. (From Merck Index, 11th ed)
Definition (NCI)	A drug used to prevent blood clots. It belongs to the family of drugs called anticoagulants.
Definition (PDQ)	A low molecular weight, synthetic heparin. As an anticoagulant/antithrombotic agent, enoxaprin's mechanism of action is similar to that of heparin, although it exhibits a higher ratio of anti-Factor Xa to anti-Factor IIa activity. This agent also has anti-inflammatory properties, inhibiting monocyte adhesion to tumor necrosis factor alpha- or lipopolysaccharide-activated endothelial cells. Compared to unfractionated heparins, the use of enoxaparin is associated with lower incidences of osteoporosis and heparin-induced thrombocytopenia. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=37880&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=37880&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C1452" NCI Thesaurus)
Definition (NCI)	A low molecular weight, synthetic heparin. As an anticoagulant/antithrombotic agent, enoxaprin's mechanism of action is similar to that of heparin, although it exhibits a higher ratio of anti-Factor Xa to anti-Factor IIa activity. This agent also has anti-inflammatory properties, inhibiting monocyte adhesion to tumor necrosis factor alpha- or lipopolysaccharide-activated endothelial cells. Compared to unfractionated heparins, the use of enoxaparin is associated with lower incidences of osteoporosis and heparin-induced thrombocytopenia. (NCI04)
Concepts	Carbohydrate (T118) , Pharmacologic Substance (T121)
MSH	D017984
English	Enoxaparin, ENOXAPARIN PREPARATION, Enoxaparine
Spanish	enoxaparina
Parent Concepts	Heparin, Low-Molecular-Weight (C0019139), Anticoagulants (C0003280)
Sources	MSH, NCI, NDFRT, PDQ, RXNORM, SCTSPA, SNOMEDCT, VANDF Derived from the NIH UMLS (Unified Medical Language System)

Dalteparin (C0206461)
Definition (NCI)	A drug that helps prevent the formation of blood clots; it belongs to the family of drugs called anticoagulants.
Definition (PDQ)	A low molecular weight, synthetic heparin. As an anticoagulant/antithrombotic agent, dalteparin binds to antithrombin and enhances the inhibition of Factor Xa. Compared to unfractionated heparins, the use of dalteparin is associated with lower incidences of osteoporosis and heparin-induced thrombocytopenia. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=43290&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=43290&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C1453" NCI Thesaurus)
Definition (NCI)	A low molecular weight, synthetic heparin. As an anticoagulant/antithrombotic agent, dalteparin binds to antithrombin and enhances the inhibition of Factor Xa. Compared to unfractionated heparins, the use of dalteparin is associated with lower incidences of osteoporosis and heparin-induced thrombocytopenia. (NCI04)
Definition (MSH)	A low-molecular-weight fragment of heparin, prepared by nitrous acid depolymerization of porcine mucosal heparin. The mean molecular weight is 4000-6000 daltons. It is used therapeutically as an antithrombotic agent. (From Merck Index, 11th ed)
Concepts	Carbohydrate (T118) , Pharmacologic Substance (T121)
MSH	D017985
English	DAL, Dalteparin, DALTEPARIN PREPARATION, Tedelparin
Spanish	dalteparina
Parent Concepts	Heparin, Low-Molecular-Weight (C0019139), Matrix Metalloproteinase Inhibitor (C1513016), Anticoagulants (C0003280), Dalteparin (C0206461)
Sources	MSH, MTH, NCI, NDFRT, PDQ, RXNORM, SCTSPA, SNOMEDCT, VANDF Derived from the NIH UMLS (Unified Medical Language System)

tinzaparin (C0216278)
Concepts	Carbohydrate (T118) , Pharmacologic Substance (T121)
MSH	C081247
English	tinzaparin, TINZAPARIN PREPARATION
Spanish	tinzaparina
Parent Concepts	Anticoagulants (C0003280), Heparin, Low-Molecular-Weight (C0019139)
Sources	MSH, NDFRT, RXNORM, SCTSPA, SNOMEDCT, VANDF Derived from the NIH UMLS (Unified Medical Language System)

danaparoid (C0259507)
Concepts	Carbohydrate (T118) , Pharmacologic Substance (T121)
MSH	C035838
English	danaparoid, DANAPAROID PREPARATION
Spanish	danaparoide
Parent Concepts	Anticoagulants (C0003280), Chondroitin Sulfates (C0008466), Dermatan Sulfate (C0011602), Heparitin Sulfate (C0019143), Heparinoids (C0019142)
Sources	MSH, NDFRT, RXNORM, SCTSPA, SNOMEDCT, VANDF Derived from the NIH UMLS (Unified Medical Language System)

Normiflo (C0297267)
Concepts	Carbohydrate (T118) , Pharmacologic Substance (T121)
MSH	C093450
English	Normiflo
Sources	MSH, RXNORM Derived from the NIH UMLS (Unified Medical Language System)

ardeparin (C0297269)
Concepts	Carbohydrate (T118) , Pharmacologic Substance (T121)
MSH	C093450
English	ardeparin, ARDEPARIN PREPARATION
Spanish	ardeparina
Parent Concepts	Anticoagulants (C0003280), Heparin, Low-Molecular-Weight (C0019139)
Sources	MSH, NDFRT, RXNORM, SCTSPA, SNOMEDCT, VANDF Derived from the NIH UMLS (Unified Medical Language System)

Innohep (C0591649)
Concepts	Carbohydrate (T118) , Pharmacologic Substance (T121)
MSH	C081247
English	Bristol-Myers Squibb brand of tinzaparin sodium, Innohep, Leo brand of tinzaparin sodium
Sources	MSH, NCI, PDQ, RXNORM Derived from the NIH UMLS (Unified Medical Language System)

Lovenox (C0728963)
Concepts	Carbohydrate (T118) , Pharmacologic Substance (T121)
MSH	D017984
English	Lovenox
Sources	MSH, NCI, PDQ, RXNORM Derived from the NIH UMLS (Unified Medical Language System)

Fragmin (C0917726)
Concepts	Carbohydrate (T118) , Pharmacologic Substance (T121)
MSH	D017985
English	Fragmin, Fragmine, Pharmacia Brand of Dalteparin Sodium, Pharmacia Spain Brand of Dalteparin Sodium
Sources	CSP, MSH, NCI, PDQ, RXNORM Derived from the NIH UMLS (Unified Medical Language System)

Hematology and Oncology Book

Anemia

Blood Transfusion

Cancer

Coagulopathy

Hemoglobinopathies

Hemolytic Disorders

Lymphatic Disorders

Pathology and Laboratory Medicine

Platelet Disorders

Obstetrics Chapter related topics

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Low Molecular Weight HeparinAka: LMW Heparin, Danaparoid, Orgaran, Tinzaparin, Innohep, Enoxaparin, Lovenox, Ardeparin, Normiflo, Dalteparin, Fragmin

Orgaran (C0163842)

Enoxaparin (C0206460)

Dalteparin (C0206461)

tinzaparin (C0216278)

danaparoid (C0259507)

Normiflo (C0297267)

ardeparin (C0297269)

Innohep (C0591649)

Lovenox (C0728963)

Fragmin (C0917726)

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