This guide intends to provide general advice on antithrombotic therapy for non-pregnant adult patients only. It is divided into 2 sections:

  1. venous thromboprophylaxis, and
  2. issues surrounding therapeutic anticoagulation, with a focus on venous thromboembolism.

 

For advice regarding thromboprophylaxis and treatment of thrombosis in pregnancy please refer to the Simpson’s Centre for Reproductive Health (SCRH) policies and Royal College of Obstetricians and Gynaecologists (RCOG) Green Top Guidance.

http://intranet.lothian.scot.nhs.uk/Directory/reproductivemedicine/policiesandguidelines/documents/maternity%20pan%20lothian/antenatal/thromboprophylaxis%20in%20pregnancy.pdf

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg37a/

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg37b/

 

Please note that this guide is intended as such. Prescribers should take account of local policy within their unit and directorate, and also individual needs of their patient.

Low molecular weight heparin (LMWH) brand on formulary

Dalteparin (Fragmin®) is currently the brand of LMWH used in NHS Lothian. It is licensed and approved for use in:

  • prophylaxis of VTE
  • treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE)

 

LMWH administration technique

Dalteparin should be administered by subcutaneous (SC) injection, while the patient is lying down, alternatively in the left and right anterolateral or posterolateral abdominal wall. Introduce the whole length of the needle vertically into a skin fold held between the thumb and index finger. Do not release the skin fold until the injection is complete and do not rub the injection site afterwards. Patients should be advised that local allergies in the form of skin erythema can occur. The patient should be advised to seek medical advice should this occur as a change in the brand of LMWH may be warranted, and the patient may require to have an FBC check to exclude heparin-induced thrombocytopenia.

 

Intravenous unfractionated heparin (UFH)

In very select circumstances where UFH is used for treatment please note that in NHS Lothian it is available in a ready made concentration of 1000 units/ml. Prescribe as “heparin 1000 units/ml”. Do not dilute this preparation. An NHS Lothian Adult Heparin Infusion Chart is available on the front page of the intranet for patients with a standard risk of bleeding.

Heparin and LMWH should be prescribed as “units” to avoid prescription errors.

 

Direct oral anticoagulant (DOAC) on formulary

Apixaban is currently the DOAC of choice in NHS Lothian.