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The treatment of choice is low molecular weight heparin (LMWH) in a once daily subcutaneous dose. Dose reductions may be indicated according to renal function and body weight. Novel agents such as oral or subcutaneous agents (fondaparinux/ dagabatrin etc) may be considered if indicated by the clinical context, with further specialist advice if necessary.
Risk of thrombocytopenia
- Platelet counts must be measured before the initiation of therapy with LMWH.
- Platelet counts should be rechecked on day 7** to monitor for thrombocytopenia.
- If platelet count is significantly reduced (30-50% of initial value) and/or patient develops new thrombosis or skin allergy during treatment, therapy must be discontinued immediately and consideration made of the appropriateness of alternative treatments.
** Thrombocytopenia can occur at any point between the 5th and 21st day post commencement- the clinical team should be aware that any signs of thrombocytopenia after 5 days post LMWH commencement will warrant a platelet count recheck.
Renal impairment
- Dosage adjustments may be required for renal impairment due to accumulation of LMWH.
- Creatinine should be checked weekly.
Hyperkalaemia
- Heparin can suppress adrenal secretion of aldosterone leading to hyperkalaemia especially in patients with diabetes mellitus, chronic renal failure, or concomitant administration of potassium sparing drugs. Urea and electrolytes should be checked weekly.
Renal impairment:
- Mild (creatinine clearance 50-80ml/min): no dosage adjustments, carefulclinical
monitoring is advised. - Moderate (creatinine clearance 30-50ml/min): no dosage adjustments, careful clinical
monitoring is advised. - Severe (creatinine clearance < 30ml/min): Dose should be reduced.
Low body weight:
- In low-weight women (< 45kg) and low-weight men (< 57kg), an increase in LMWH exposure has been observed within the prophylactic dosage ranges (non-weight adjusted), which may lead to a higher risk of bleeding. Therefore, careful clinical monitoring is advised in these patients.
- Dose should be reduced in patients below these weights.
Patients with an Australia-modified Karnofsky Performance Scale (AKPS) <50 who have been deteriorating over past 12 weeks have a 30% prevalence of femoral VTE with minimal symptoms and no survival difference to those without DVT . 18 Thromboprophylaxis could be stopped in these patients.
It is recommended that agents which affect haemostasis should be discontinued prior to LMWH therapy unless their use is essential, or warranted by the clinical situation where their benefit outweighs the risks, such as: systemic salicylates, acetylsalicylic acid, NSAIDs including ketorolac, dextran, and clopidogrel, systemic glucocorticoids, thrombolytics and other anticoagulants. If the combination cannot be avoided, LMWH should be used with careful clinical and laboratory monitoring.
Disclaimer
These Guidelines are intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
Whilst SPAGG takes every care to compile accurate information , we cannot guarantee its correctness and completeness, and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.