Protamine

Aka: Protamine

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II. Indications

  1. Heparin Reversal
  2. Low Molecular Weight Heparin (LMWH) partial reversal

III. Contraindications

  1. Prior Anaphylaxis to Protamine
  2. See Anaphylactoid Reaction below for reaction risk factors

IV. Mechanism

  1. Binds and neutralizes Heparin and partially binds and neutralizes Low Molecular Weight Heparin (LMWH)

V. Dosing: Heparin Reversal (FDA Approved)

  1. General
    1. Base Protamine on Heparin dose within the last 2 hours
      1. Heparin has a short Half-Life of less than 90 minutes
    2. Deliver Protamine slowly (rate up to 50 mg per 10 minutes)
    3. May require additional or prolonged Protamine dosing for SQ Heparin reversal
  2. Last Heparin dose in last 30 minutes
    1. Protamine 1 mg per 100 units Heparin
  3. Last Heparin dose longer than 30 minutes ago
    1. Protamine 0.5 mg per 100 units Heparin

VI. Dosing: Low Molecular Weight Heparin (LMWH) partial reversal (off-label use)

  1. Last LMWH dose in last 8 hours
    1. Protamine 1 mg per 100 anti-Xa units Dalteparin
    2. Protamine 1 mg per 1 mg Enoxaparin
  2. Last LMWH dose longer than 8 hours ago
    1. Protamine 0.5 mg per 100 anti-Xa units Dalteparin
    2. Protamine 0.5 mg per 1 mg Enoxaparin
  3. Additional dose if PTT still prolonged at 2-4 hours after Protamine infusion
    1. Protamine 0.5 mg per 100 anti-Xa units Dalteparin
    2. Protamine 0.5 mg per 1 mg Enoxaparin

VII. Adverse Effects: Anaphylactoid Reaction

  1. Risk Factors
    1. Rapid administration (limit rate to no more than 50 mg per 10 minutes)
    2. Fish allergy history
    3. Prior Protamine exposure
  2. Findings
    1. Pulmonary Edema
    2. Hypotension to the point of cardiovascular collapse
  3. Management
    1. See Anaphylaxis
  4. Prevention
    1. Consider Corticosteroid and Antihistamine pretreatment

VIII. Resources

  1. Protamine (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e1964129-33f4-4e4e-86e3-8e6a4e65bd83
  2. Medscape
    1. http://reference.medscape.com/drug/protamine-343746
  3. Global RPH
    1. http://www.globalrph.com/protamine_dilution.htm

IX. References

  1. (2010) Tarascon Pharmacopoeia

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