LSUHSC-SHREVEPORT

LSUHSC-SHREVEPORT

Low Molecular Weight Heparin Equivalency and Conversion

Indication	Patient Type	enoxaparin dose (Lovenox)	change to dalteparin (Fragmin)
DVT/PE prophylaxis	Surgical High Risk (abdominal, pelvis, & lower extremity)	40mg SQ QD 30mg SQ q 12h	5000u SQ QD 5000u SQ QD
	Surgical Moderate Risk	30mg SQ QD 30mg SQ BID	2500u SQ QD 2500u SQ QD
	Orthopedic Surgery	30mg SQ q 12h 40mg SQ QD	5000u SQ QD 5000u SQ QD
	Medical	30mg SQ BID	2500u SQ QD
DVT/PE treatment	All patients	1mg/kg SQ q 12h	200u/kg SQ QD - (max 18,000u/day)
Acute Coronary Syndrome Treatment	All patients	1mg/kg SQ q 12h	120u/kg SQ q 12h (max 10,000u SQ q 12h)

The Low Molecular Weight Heparin conversion shall be automatic.

Pharmacists shall perform the conversion at the time of order entry. Orders shall be written according to Clinical Board protocol and shall contain the pharmacist’s signature.

The pharmacist shall evaluate all new orders as to the need for dosage adjustment in patients with decreased renal function, and the physician contacted if dosage reductions should be considered.

Use of alternative low molecular weight heparins must be approved by the Associate Dean for Clinical Affairs or his designee.

Orthopedic Surgery

Day of Surgery	Following days
2500u SQ 4-8 hours after surgery*	Continue 5000u SQ once daily1

Preoperative start: 2500u SQ £ 2 hours preoperatively and 2500u SQ 4 to 8 hours after surgery,* (2 ) or 5000u SQ 10 to 14 hours before surgery and 5000u SQ 4 to 8 hours after surgery* (allow approximately 24 hours between doses); continue 5000u SQ once daily. (1 )

*Or later, if hemostasis has not been achieved.

(1 ) Up to 14 days of treatment was well tolerated in controlled clinical trials, where the average duration of treatment was 5-10 days postoperatively.

(2 ) At least 6 hours after first dose.

References: 1. Hull RD, et al. Low-molecular-weight heparin prophylaxis using dalteparin in close proximity to surgery vs warfarin in hip arthroplasty patients. Arch Intern Med 2000; 160:2199-2207.

2. Hull RD, et al. Low-molecular weight heparin prophylaxis using dalteparin extended out-of-hospital vs in-hospital warfarin/out-of-hospital placebo in hip arthroplasty patients. Arch Intern Med 2000; 160:2208-2215.