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Monday, February 7, 2011

Dalteparin

Posted by Sampil 5:18 PM, under | No comments

dalteparin
(dahl' tep ah rin)
Fragmin

Pregnancy Category B

Drug classes
Anticoagulant
Antithrombotic
Low-molecular-weight heparin

Therapeutic actions
Low-molecular-weight heparin that inhibits thrombus and clot formation by blocking factor Xa, factor IIa, preventing the formation of clots.

Indications
·        Treatment of unstable angina and non–Q-wave MI for the prevention of complications in patients on aspirin or standard therapy
·        Prevention of DVT, which may lead to pulmonary embolism, following abdominal or hip replacement surgery
·        Unlabeled use: Systemic anticoagulation in venous and arterial thromboembolic complications; prophylaxis of DVT in situations that may lead to PE; adjunct to antineoplastic chemotherapy

Contraindications and cautions
·        Contraindicated with hypersensitivity to dalteparin, heparin, pork products, or benzyl alcohol; severe thrombocytopenia; uncontrolled bleeding; use of unstable angina dosage in patients undergoing regional anesthesia; pregnancy.
·        Use cautiously with lactation; history of GI bleed; severe liver or renal dysfunction; recent childbirth or surgery; history of heparin-induced thrombocytopenia; severe and uncontrolled hypertension, spinal tap, spinal/epidural anesthesia.

Available forms
Injection—2,500 IU/0.2 mL, 5,000 IU/0.2 mL

Dosages
ADULTS
·        Unstable angina: 120 IU/kg subcutaneously q 12 hr with aspirin therapy for 5–8 days; not to exceed 10,000 IU q 12 hr.
·        DVT prophylaxis, abdominal surgery: 2,500 IU subcutaneously given 1–2 hr before surgery and repeated once daily for 5–10 days after surgery; high-risk patients, 5,000 IU subcutaneously starting the evening before surgery; then daily for 5–10 days.
·        Hip replacement surgery: 5,000 IU subcutaneously the evening before surgery or 2,500 IU within 2 hr before surgery or 2,500 IU 4–8 hr after surgery; then, 5,000 IU subcutaneously each day for 5–10 days or up to 14 days.
PEDIATRIC PATIENTS
Safety and efficacy not established.

Pharmacokinetics
Route
Onset
Peak
Duration
SC
20–60 min
3–5 hr
2–12 hr
Metabolism: T1/2: 4.5 hr
Distribution: May cross placenta, may enter breast milk
Excretion: Urine

Adverse effects
·        Hematologic: Hemorrhage; bruising; thrombocytopenia
·        Hepatic: Elevated concentrations of AST, ALT
·        Hypersensitivity: Chills, fever, urticaria, asthma
·        Other: Fever; pain; local irritation, hematomaerythema at site of injection; risk of spinal or epidural hematoma if used with spinal/epidural anesthesia or spinal tap

Interactions
·        Increased bleeding tendencies with oral anticoagulants or platelet inhibitors; clopidogrel, ticlopidine, salicylates
·        Risk of severe bleeding with heparin; avoid this combination
·        Increased AST, ALT levels
·        Increased risk of bleeding if combined with chamomile, garlic, ginger, ginkgo, and ginseng therapy, high-dose vitamin E

Nursing considerations
Assessment
·        History: Recent surgery or injury; sensitivity to heparin, pork products, either low–molecular-weight heparins or enoxaparin, tinzaparin, benzyl alcohol; lactation, pregnancy; history of GI bleed; renal or liver dysfunction
·        Physical: Peripheral perfusion, R, stool guaiac test, PTT or other tests of blood coagulation, platelet count, renal function tests

Interventions
·        Give 1–2 hr before abdominal surgery.
·        Give deep subcutaneous injections; do not give dalteparin by IM injection.
·        Administer by deep subcutaneous injection; patient should be lying down; alternate administration between the left and right anterolateral and left and rightposterolateral abdominal wall. Introduce the whole length of the needle into a skin fold at a 45° and 90° angle held between the thumb and forefinger; hold the skin fold throughout the injection.
·        Cannot be used interchangeably (unit for unit) with other low-molecular-weight heparin or unfractionated heparin.
·        Apply pressure to all injection sites after needle is withdrawn; inspect injection sites for signs of hematoma.
·        Do not massage injection sites.
·        Do not mix with other injections or infusions.
·        Store at room temperature; fluid should be clear, colorless to pale yellow.
·        Alert all health care providers that patient is on dalteparin.
·        If thromboembolic episode should occur despite therapy, discontinue and initiate appropriate therapy.
·        WARNING: Keep protamine sulfate (dalteparin antidote) readily available in case of overdose.
·        Treatment of overdose: Protamine sulfate (1% solution). Administer 1 mg of protamine per 100 antifactor Xa IU of dalteparin. Give very slowly IV over 10 min.

Teaching points
·        This drug must be given by a parenteral route (not orally). You and a significant other may need to learn to administer the drug subcutaneously, and to safely dispose of syringes.
·        Periodic blood tests are needed to monitor response.
·        Avoid injury while using this drug—use an electric razor, avoid potentially injurious activities.
·        Report nose bleed, bleeding of the gums, unusual bruising, black or tarry stools, cloudy or dark urine, abdominal or lower back pain, severe headache.

Adverse effects in Italic are most common; those in Bold are life-threatening.

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