Dalteparin

Class
Anticoagulants
Subclass
Low molecular weight heparins
Substance name
Dalteparin sodium
Brand names
Fragmin®
Common formulations
Solution for injection
Dosage and administration
Adults patients
Treatment
VTE in patients with cancer • Extended treatment
•
Start at: 200 unit(s)/kg SC q24h for 1 month
•
Maintenance: 150 unit(s)/kg SC q24h for 5 months
•
Maximum: 18,000 unit(s) per day
Cerebral venous thrombosis • Off-label
•
100 unit(s)/kg SC q12h for 12 days
PE • Off-label
•
100 unit(s)/kg SC q12h for at least 5 days and until the INR is ≥ 2 for at least 24 hours
Alternative
•
200 unit(s)/kg SC q24h for at least 5 days and until the INR is ≥ 2 for at least 24 hours
VTE in patients with cancer • Off-label
•
Start at: 100 unit(s)/kg SC q12h, followed by 200 unit(s)/kg × 1 daily for 1 month
•
Maintenance: 150 unit(s)/kg SC q24h
Alternative
•
Start at: 200 unit(s)/kg SC q24h, followed by 200 unit(s)/kg × 1 daily for 1 month
•
Maintenance: 150 unit(s)/kg SC q24h
VTE in pregnant females • Off-label
•
5,000 unit(s) SC q12h
Alternative
•
200 unit(s)/kg SC q24h
Alternative
•
100 unit(s)/kg SC q12h
Adjunctive treatment
Adjunctive treatment for non-ST-elevation acute coronary syndrome
•
Maintenance: 120 unit(s)/kg SC q12h for 5-8 days and until clinical stabilization
•
Maximum: 10,000 unit(s) per day
Administered in combination with aspirin.
Prevention
DVT in patients with acute Illness
•
5,000 unit(s) SC q24h for 12-14 days
DVT in patients with cancer, during abdominal surgery
•
Start at: 5,000 unit(s) SC × 1 10-14 hours before surgery
•
Maintenance: 5,000 unit(s) SC q24h for 5-10 days
Alternative
•
Loading: 2,500 unit(s) SC × 1 1-2 hours before surgery
•
Subsequently: 2,500 unit(s) SC × 1 for 12 hours later
•
Maintenance: 5,000 unit(s) SC q24h for 5-10 days
DVT, during abdominal surgery
•
Start at: 2,500 unit(s) SC × 1 1-2 hours before surgery
•
Maintenance: 2,500 unit(s) SC q24h for 5-10 days
DVT, during hip replacement
•
Start at: 2,500 unit(s) SC × 1 4-8 hours after surgery (postoperative start)
•
Maintenance: 5,000 unit(s) SC q24h for 5-10 days days, and up to 35 days
Alternative
•
Loading: 2,500 unit(s) SC × 1 2 hours before surgery (preoperative start)
•
Subsequently: 2,500 unit(s) SC × 1 4-8 hours after surgery
•
Maintenance: 5,000 unit(s) SC q24h for 5-10 days days, and up to 35 days
Alternative
•
Start at: 5,000 unit(s) SC × 1 10-14 hours before surgery (preoperative start)
•
Maintenance: 5,000 unit(s) SC q24h for 5-10 days days, and up to 35 days
Arterial thromboembolism • Perioperative bridging of VKA therapy, during surgery • Off-label
•
100 unit(s)/kg SC q12h, with the last preoperative dose given 24 hours before surgery and resumed at least 24 hours postoperatively (48-72 hours for high-risk procedures), continued until therapeutic INR is achieved
Consider administering a half dose for the preoperative dose in high-risk procedures.
Alternative
•
200 unit(s)/kg SC q24h, with the last preoperative dose given 24 hours before surgery and resumed at least 24 hours postoperatively (48-72 hours for high-risk procedures), continued until therapeutic INR is achieved
Consider administering a half dose for the preoperative dose in high-risk procedures.
Prosthetic valve thrombosis • Bridging • Off-label
•
5,000 unit(s) SC q24h until stable on VKA therapy
Alternative
•
100 unit(s)/kg SC q12h until stable on VKA therapy
Alternative
•
200 unit(s)/kg SC q24h until stable on VKA therapy
VTE in patients with cancer • Off-label
•
5,000 unit(s) SC q24h
Administer 2,500 or 5,000 unit(s) 2-4 before surgery and daily thereafter for at least 7-10 days.
VTE in pregnant females • Off-label
•
5,000 unit(s) SC q24h
Indications for use
Labeled indications
Adults
•
Treatment of VTE in patients with cancer (extended treatment)
•
Adjunctive treatment for non-ST-elevation acute coronary syndrome
•
Prevention of DVT in patients with acute Illness
•
Prevention of DVT in patients with cancer, in patients undergoing abdominal surgery
•
Prevention of DVT, in patients undergoing abdominal surgery
•
Prevention of DVT, in patients undergoing hip replacement
Off-label indications
Adults
•
Treatment of cerebral venous thrombosis
•
Treatment of PE
•
Treatment of VTE in patients with cancer
•
Treatment of VTE in pregnant females
•
Prevention of arterial thromboembolism (perioperative bridging of VKA therapy), in patients undergoing surgery
•
Prevention of prosthetic valve thrombosis (bridging)
•
Prevention of VTE in patients with cancer
•
Prevention of VTE in pregnant females
Safety risks
Boxed warnings
Epidural hematoma, spinal hematoma
•
Do not use dalteparin as a treatment for unstable angina or NSTEMI or for prolonged VTE prophylaxis in patients receiving neuraxial anesthesia or undergoing spinal puncture. Use extreme caution for other indications in patients receiving neuraxial anesthesia or undergoing spinal puncture, especially if risk factors for hemorrhage are present, such as an indwelling epidural catheter, concomitant drugs affecting hemostasis (such as non-steroidal anti-inflammatory drugs, platelet inhibitors, anticoagulants), a history of traumatic or repeated epidural or spinal punctures, or a history of spinal deformity or spinal surgery. Monitor patients frequently for signs and symptoms of neurological impairment.
Contraindications
Hypersensitivity to dalteparin or its components
Active major bleeding
History of heparin-induced thrombocytopenia
Warnings and precautions
Decreased platelet count
•
Maintain a high level of suspicion, as thrombocytopenia can occur with the use of dalteparin.
Gasping syndrome
•
Use caution in infants, as dalteparin sodium vials contain benzyl alcohol preservative.
Hemorrhage
•
Use extreme caution in patients at high risk of hemorrhage, including bacterial endocarditis, congenital or acquired bleeding disorders, active ulcerative or angiodysplastic gastrointestinal disease, hemorrhagic stroke, recent brain, spinal, or ophthalmologic surgery, or concomitant use of platelet inhibitors.
•
Use caution in patients with thrombocytopenia or platelet defects, severe liver or kidney insufficiency, hypertensive or diabetic retinopathy, or recent gastrointestinal bleeding.
Heparin-induced thrombocytopenia
•
Maintain a high level of suspicion, as dalteparin may cause heparin-induced thrombocytopenia with or without thrombosis.
Specific populations
Renal impairment
eGFR ≥ 30 mL/min/1.73 m²
•
Use acceptable. No dose adjustment required.
eGFR < 30 mL/min/1.73 m²
•
Reduce dose during extended treatment of acute symptomatic venous thromboembolism in adult patients with cancer. Monitor anti-Xa levels to determine the appropriate dose, targeting an anti-Xa range of 0.5-1.5 unit(s)/mL. Sample blood 4-6 hours after dalteparin dosing and only after the patient has received 3-4 doses.
Renal replacement therapy
Any modality
•
Use acceptable. No dose adjustment required. Monitor anti-factor Xa levels. Monitor for bleeding.
Hepatic impairment
Any severity
•
Use acceptable. No dose adjustment required.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: C
•
Use only if clearly needed. Use preservative-free formulations.
Breastfeeding
Acceptable for use during breastfeeding.
Unknown drug levels in breastfed infants.
No overt adverse effects reported in breastfed infants.
Adverse reactions
Common 1-10%
•
Hemorrhage, ↑ serum transaminases, injection site hematoma, hematuria, injection site pain
Unknown frequency
•
Anaphylactoid reactions, osteoporosis, spinal hematoma, epidural hematoma, skin rash, fever, itching, hair loss, skin necrosis, ↑ serum potassium, ↓ platelet count
Interactions
Drug(s)
Check Interactions
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