page165
minute/1.73 m
2
,
but avoid or stop infusion if eGFR
less than 15 mL/minute/1.73 m
2
(consult product lit-
erature)
Pregnancy
avoid
Breast-feeding
avoid
Side-effects
bleeding;
reduced haemoglobin concen-
tration without obvious source of bleeding;
fever,
hypersensitivity reactions (including rash);
injection-
site reactions
Dose
. Initially by slow intravenous injection (of 5 mg/mL
solution), 400 micrograms/kg followed by continuous
intravenous infusion
of 150 micrograms/kg/hour
(max. 16.5 mg/hour), adjusted according to activated
partial thromboplastin time,
for 2–10 days (longer if
necessary)
Refludan
c
(Celgene) A
Injection
,
powder for reconstitution,
lepirudin,
net
price 50-mg vial = £57.00
Heparin flushes
The use of heparin flushes should be kept to a minimum.
For maintaining patency of peripheral venous catheters,
sodium chloride injection 0.9% is as effective as heparin
flushes.
The role of
heparin flushes
in maintaining
patency of
arterial
and central
venous
catheters
is
unclear.
Heparin Sodium
(Non-proprietary) A
Solution
,
heparin sodium 10 units/mL,
net price 5-
mL amp = £1.00;
100 units/mL,
2-mL amp = £1.05
Dose
to maintain patency of catheters,
cannulas,
etc. 10–
200 units flushed through every 4–8 hours. Not for therapeutic use
Excipients
may include benzyl alcohol (avoid in neonates,
see Excipi-
ents, p.
2)
Epoprostenol
Epoprostenol
(prostacyclin)
can be given to inhibit
platelet aggregation during renal dialysis when heparins
are unsuitable or contra-indicated. It is also licensed for
the treatment of primary pulmonary hypertension resis-
tant
to
other
treatment,
usually
with
oral
anti-
coagulation.
Since its half-life is only about 3 minutes
it must be given by continuous intravenous infusion. It is
a
potent
vasodilator
and
therefore
its
side-effects
include flushing,
headache,
and hypotension.
EPOPROSTENOL
Indications
see notes above
Cautions
anticoagulant monitoring required when
given with anticoagulants;
haemorrhagic diathesis;
dose titration for pulmonary hypertension should be
in hospital (risk of pulmonary oedema); concomitant
use of drugs that increase risk of bleeding
Contra-indications
severe left ventricular dysfunction
Pregnancy
manufacturer advises caution—no infor-
mation available
Side-effects
see notes above;
also bradycardia,
tachycardia, pallor,
sweating with higher doses;
gas-
tro-intestinal disturbances;
lassitude,
anxiety,
agita-
tion;
dry mouth,
jaw pain,
chest pain;
also reported,
hyperglycaemia and injection-site reactions
Dose
. See product literature
Flolan
c
(GSK) A
Infusion
, powder for reconstitution, epoprostenol (as
sodium salt),
net price 500-microgram vial (with
diluent) = £62.05;
1.5-mg vial (T) (with diluent) =
£125.00
Fondaparinux
Fondaparinux sodium is a synthetic pentasaccharide
that inhibits activated factor X.
For details on the use of fondaparinux in the prophylaxis
of venous thromboembolism,
see section 2.8,
p.
140.
FONDAPARINUX SODIUM
Indications
prophylaxis of venous thromboembolism
in medical patients immobilised because of acute
illness,
and patients undergoing major orthopaedic
surgery of the hip or leg,
or abdominal surgery;
treatment of deep-vein thrombosis,
superficial-vein
thrombosis,
and pulmonary embolism;
treatment of
unstable angina or non-ST-segment elevation myo-
cardial infarction;
treatment of ST-segment elevation
myocardial infarction
Cautions
bleeding disorders,
active gastro-intestinal
ulcer disease; recent intracranial haemorrhage; brain,
spinal,
or ophthalmic surgery;
spinal or epidural
anaesthesia (risk of spinal haematoma—avoid if using
treatment doses);
risk of catheter thrombus during
percutaneous coronary intervention;
low body-
weight; elderly patients; concomitant use of drugs that
increase risk of bleeding
Contra-indications
active bleeding;
bacterial endo-
carditis
Hepatic impairment
caution in severe impairment
(increased risk of bleeding)
Renal impairment
increased risk of bleeding;
for
treatment of acute coronary syndromes
avoid if eGFR
less than 20 mL/minute/1.73 m
2
;
for
treatment of
venous thromboembolism
use with caution if eGFR
30–50 mL/minute/1.73 m
2
,
avoid if eGFR less than
30 mL/minute/1.73 m
2
;
for
prophylaxis of venous
thromboembolism
and
treatment of superficial-vein
thrombosis
reduce dose to 1.5 mg daily if eGFR 20–
50 mL/minute/1.73 m
2
,
avoid if eGFR less than
20 mL/minute/1.73 m
2
Pregnancy
manufacturer advises avoid unless poten-
tial benefit outweighs possible risk—no information
available
Breast-feeding
present in milk in
animal
studies—
manufacturer advises avoid
Side-effects
bleeding,
purpura,
anaemia;
less com-
monly
gastro-intestinal disturbances, oedema, hepatic
impairment, chest pain, dyspnoea, thrombocytopenia,
thrombocythaemia,
rash,
pruritus;
rarely
hypo-
tension,
flushing,
cough, vertigo,
dizziness,
anxiety,
drowsiness,
confusion, headache,
hypokalaemia,
hyperbilirubinaemia, injection-site reactions; also
reported atrial fibrillation, tachycardia, and pyrexia
Dose
.
Prophylaxis of venous thromboembolism after sur-
gery,
by subcutaneous injection,
2.5 mg 6 hours
after surgery then 2.5 mg once daily;
CHILD
under
17 years not recommended
BNF 61
2.8.1 Parenteral anticoagulants
145
2
Cardiovascular system