anticoag 2

All doses of enoxaparin must be rounded to the nearest 10 mg. – Do automatically send therapeutic interchange sheet

• No
• You do not have to ask prescriber if you can change frequency unless they write No Substitution……………….

• MAXIMUM dose Enoxaparin
• 190mg subcutaneously every 12 hours OR 190mg subcutaneously q24hrs

• CrCl 20-29ml/min-
• Decrease Enoxaprin to 1mg/kg SC q24h

• CrCl < 20 ml/min
• or dialysis must use WBH
• because (enoxaparin contraindicated)

• #1 Platelets - Monitoring for Heparin-Induced Thrombocytopenia (HIT)
• If decrease in platelets >40%, call prescriber

• (MONITOR patients carefully)·
• #2 If it decreases platelets >50% from baseline - Call MD to D/C all Enoxaparin/Heparin (including heparin-coated catheters)

Recommend Heparin-Antibody Test (HIT screen)·

For continuous therapeutic anticoagulation- (AF, ACS, DVT/PE) recommend a Direct Thrombin Inhibitor (Argatroban) or fondaparinux-choice based on Renal and/or Hepatic disease

150 mg Lovenox q24hr

Lovenox 1 mg/kg SC q12hr

Lovenox 1mg/kg sc q12h

max dose 190mg q12h

Weight > 190 kg or < 45 kg

Recommend Weight Based Heparin

• Lovenox dose in decreased renal function 
• CrCl 20-29 ml/minute 1 mg/kg. q24h dosing CrCl < 20 ml/minute Recommend Weight Based Heparin

• Weight > 190 kg or < 45 kg Recommend Weight Based Heparin
• Calculating Lovenox Dose Round ALL doses to nearest 10 mg.
• Maximum Single Dose 190 mg. subcutaneously
• CrCl 20-29 ml/minute 1 mg/kg. q24h dosing

CrCl < 20 ml/minute Recommend Weight Based HeparinMD order for DVT/PE Treatment 1 mg/kg q12h may be AutomaticallyConverted to 1.5 mg/kg q24h/MEC approval if pt meets criteria above.

Double-Check Wt/CrCl, Calculate dose, enter order, send interchange orderDocument with clinical intervention.

Recent FDA Drug Safety communication warning that doses of citalopram above 40 mg/day can cause dose-dependent QT inteval prolongation, which may result in abnormal heart rhythms.

15-20 mcg/ml

As a rule, we have been using a minimum SCr of 0.8 in patients over 65 so as not to over estimate CrCl due to age-related decline in renal function. This may be causing some under dosing in our “not so old” elderly patients.

In patients over 65 with a SCr above 0.6, consider using actual SCr.·

Critically ill patients tend to have increased volume of distribution of vanco as well as increase clearance. With initial dosing, error on the “high side” ex. 750 mg IV q12h would give you a predicted trough of 16 mcg but 1 gm IV q12h predicts a trough of 21; in an acutely ill patient with stable RF, I would go with the 1 gm IV q12h, order a trough prior to the 4th dose, and adjust as necessary.·

Remember to order a Vancomycin loading dose

3.375 gm q6hr

then renal dose to whatever the next interval is….it is absolutely ok to give q8h if that is the corresponding interval to pts crcl..

We need to determine if it is a nosocomial pneumonia or not 1st with high suspicion of pseudomonas….if so initial dose 4.5 g q6 then renal dose from there

We have approved the guideline through P&T and MEC that clinical staff pharmacists will automatically change dosing of 1 mg./kg q12h to 1.5 mg/kg q24h for pts that meet dosing parameters.

.It would be extremely helpful if you order the full dose of 1.5 mg./kg q24h for initial dose…

Dosing guidelines for enoxaparin for DVT/PE· If pt has creatinine clearance > 30 ml/minute and wt is 45-129 kg they may receive 1.5 mg/kg q24h·

If wt 130-190 and CrCl >30 ml/minute dosing 1 mg/kg q12h with max dosing 190 mg. q12h·

If creatinine clearance is 20-30 ml/minute the dose is 1 mg/kg q24h·

If pt on dialysis or creatinine clearance <20 ml/minute or wt <45 or >190 kg enoxaparin contraindicated order WBH…..

We recommend that you may also order “Enoxaparin dosing per pharmacist for DVT/PE”In this scenario the pharmacist will be able to access all above parameters and order dose…. We plan to update a DVT/PE Clinical Pathway in the near future to build dosing into ED and Inpatient CPOE Please note: IHI recommends using enoxaparin in place of WBH if pt meets dosing parameters unless pt scheduled for procedure or has bleeding co-morbidities.WBH is a high-risk drug which offers potential for errors due to need for monitoring PTT and continuous infusion. Enoxaparin has a beneficial safety profile in this pt population

Unless pt scheduled for procedure or has bleeding co-morbidities.

WBH is a high-risk drug which offers potential for errors due to need for monitoring PTT and continuous infusion. Enoxaparin has a beneficial safety profile in this pt population