Table 3.
Dosing regimens for prevention and treatment of VTE in patients with malignancy (Adapted from ASCO [7])
| Drug | Regimen |
|---|---|
| Pharmacologic (anticoagulant) prophylaxisa | |
| Hospitalized medical patientsb | |
| Unfractionated heparin | 5000 U once every 8 hc |
| Dalteparin | 5000 U once daily |
| Enoxaparin | 40 mg once daily |
| Fondaparinux | 2.5 mg once daily |
| Surgical patientsb,d | |
| Unfractionated heparin | 5000 U 2–4 h preoperatively and once every 8 hours thereafter or 5000 U 10–12 h preoperatively and 5000 U once daily thereafterc |
| Dalteparin | 2500 U 2–4 h preoperatively and 5000 U once daily thereafter or 5000 U 10–12 h preoperatively and 5000 U once daily thereafter |
| Enoxaparin | 20 mg 2–4 h preoperatively and 40 mg once daily thereafter or 40 mg 10–12 h preoperatively and 40 mg once daily thereafter |
| Fondaparinux | 2.5 mg qd beginning 6–8 h postoperatively |
| Treatment of established VTE | |
| Initial | |
| Unfractionated heparine | 80 U/kg IV bolus, then 18 U/kg per hour IV; adjust dose based on aPTTh |
| Dalteparine,g,h | 100 U/kg once every 12 h; 200 U/kg once daily |
| Enoxoparine,g,h,i | 1 mg/kg once every 12 h; 1.5 mg/kg once daily |
| Tinzaparine,g,h,j | 175 U/kg once per day |
| Fondaparinuxe,g | <50 kg, 5.0 mg once daily; 50–100 kg, 7.5 mg once daily; >100 kg, 10 mg once daily |
| Long termk | |
| Dalteparinh,g | 200 U/kg once daily for 1 month, then 150 U/kg once daily |
| Enoxaparing,h,i | 1.5 mg/kg once daily; 1 mg/kg once every 12 h |
| Tinzaparinh,j | 175 U/kg once daily |
| Warfarin | Adjust dose to maintain INR 2–3 |
aPTT activated partial thromboplastin time, FDA US Food and Drug Administration, INR international normalized ratio, IV intravenous, LMWH low-molecular weight heparin, VTE venous thromboembolism
aAll doses are administered as subcutaneous injections except as indicated
bDuration for medical patients is length of hospital stay or until fully ambulatory; for surgical patients, prophylaxis should be continued for at least 7–10 days. Extended prophylaxis for up to 4 weeks should be considered for high-risk patients
cUnfractionated heparin 5000 U every 12 h has also been used but appears to be less effective
dWhen neuraxial anesthesia or analgesia is planned, prophylactic doses of once-daily LMWH should not be administered within 10–12 h before the procedure/instrumentation (including epidural catheter removal). After surgery, the first dose of LMWH can be administered 6–8 h postoperatively. After catheter removal the first dose of LMWH can be administered no earlier than 2 h afterward. Clinicians should refer to their institutional guidelines and the American Society of Regional Anesthesia Guidelines for more information
eParenteral anticoagulants should overlap with warfarin for 5–7 days minimum and continued until INR is in the therapeutic range for 2 consecutive days
fUnfractionated heparin infusion rate should be adjusted to maintain the aPTT within the therapeutic range in accordance with local protocol to correspond with a heparin level of 0.3–0.7 U/mL using a chromogenic Xa essay
gDependent on significant renal clearance; avoid in patients with creatinine clearance ≤30 mL/min or adjust dose based on anti-factor Xa levels
hOptimal dose unclear in patients >120 kg
iTwice-daily dosing may be more efficacious than once-daily dosing for enoxaparin based on post hoc data
jThis drug is not available in the United States
kTotal duration of therapy depends on clinical circumstances. See Clinical Question 4, section entitled “Initial Long-Term Treatment Up to 6 Months,” for more detailed discussion