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Heparin

Intravenous
Subcutaneous
Intracatheter
Class
Anticoagulants
Subclass
Heparins
Generic name
Heparin sodium, unfractionated heparin, UFH
Common formulations
Solution for injection
Dosage and administration
Adults patients
Treatment
Arterial thromboembolism
•
Start at: 60-80 unit(s)/kg IV once, capped at 5,000-10,000 units (depending on desired rapidity and intensity of anticoagulation)
•
Maintenance: 10-20 unit(s)/kg/h IV continuous infusion, capped at 1,250 units/hour (titrate per aPTT or anti-Xa according to institutional guidelines)
•
Maximum: 30,000 unit(s) per day
Titrate per aPTT (usual goal 1.5-2.5× baseline) or anti-Xa levels (usual goal 0.3-0.7 IU/mL) based on institutional guidelines. Consider favoring anti-Xa level monitoring in patients with obesity (e.g. > 120 kg), heparin resistance (e.g. requiring ≥ 35,000 units of heparin per day to achieve aPTT targets), lupus anticoagulant, DIC, direct thrombin inhibitor exposure (e.g., argatroban), as well as in pregnant patients.
VTE
•
Start at: 60-80 unit(s)/kg IV once, capped at 5,000-10,000 units (depending on desired rapidity and intensity of anticoagulation)
•
Maintenance: 10-20 unit(s)/kg/h IV continuous infusion, capped at 1,250 units/hour (titrate per aPTT or anti-Xa according to institutional guidelines)
•
Maximum: 30,000 unit(s) per day
Titrate per aPTT (usual goal 1.5-2.5× baseline) or anti-Xa levels (usual goal 0.3-0.7 IU/mL) based on institutional guidelines. Consider favoring anti-Xa level monitoring in patients with obesity (e.g. > 120 kg), heparin resistance (e.g. requiring ≥ 35,000 units of heparin per day to achieve aPTT targets), lupus anticoagulant, DIC, direct thrombin inhibitor exposure (e.g., argatroban), as well as in pregnant patients.
Adjunctive treatment
Non-ST elevation acute coronary syndrome, before PCI • Off-label
•
Start at: 60-80 unit(s)/kg IV once, capped at 5,000 units
•
Maintenance: 10-20 unit(s)/kg/h IV continuous infusion, capped at 1,250 units/hour (titrate per aPTT or anti-Xa according to institutional guidelines)
•
Maximum: 30,000 unit(s) per day
Titrate per aPTT (usual goal 1.5-2.5× baseline) or anti-Xa levels (usual goal 0.3-0.7 IU/mL) based on institutional guidelines. Consider favoring anti-Xa level monitoring in patients with obesity (e.g. > 120 kg), heparin resistance (e.g. requiring ≥ 35,000 units of heparin per day to achieve aPTT targets), lupus anticoagulant, DIC, direct thrombin inhibitor exposure (e.g., argatroban), as well as in pregnant patients.
STEMI, during fibrinolytic therapy • Off-label
•
Start at: 60-80 unit(s)/kg IV once, capped at 5,000 units
•
Maintenance: 10-20 unit(s)/kg/h IV continuous infusion, capped at 1,250 units/hour (titrate per aPTT or anti-Xa according to institutional guidelines)
•
Maximum: 30,000 unit(s) per day
Titrate per aPTT (usual goal 1.5-2.5× baseline) or anti-Xa levels (usual goal 0.3-0.7 IU/mL) based on institutional guidelines. Consider favoring anti-Xa level monitoring in patients with obesity (e.g. > 120 kg), heparin resistance (e.g. requiring ≥ 35,000 units of heparin per day to achieve aPTT targets), lupus anticoagulant, DIC, direct thrombin inhibitor exposure (e.g., argatroban), as well as in pregnant patients.
STEMI, during PCI • Off-label
•
Start at: 60-80 unit(s)/kg IV once, capped at 5,000 units
•
Maintenance: 10-20 unit(s)/kg/h IV continuous infusion, capped at 1,250 units/hour (titrate per aPTT or anti-Xa according to institutional guidelines)
•
Maximum: 30,000 unit(s) per day
Titrate per aPTT (usual goal 1.5-2.5× baseline) or anti-Xa levels (usual goal 0.3-0.7 IU/mL) based on institutional guidelines. Consider favoring anti-Xa level monitoring in patients with obesity (e.g. > 120 kg), heparin resistance (e.g. requiring ≥ 35,000 units of heparin per day to achieve aPTT targets), lupus anticoagulant, DIC, direct thrombin inhibitor exposure (e.g., argatroban), as well as in pregnant patients.
Prevention
Prevention of thromboembolism in patients with AF, during cardioversion • Off-label
•
Start at: 60-80 unit(s)/kg IV once, capped at 5,000 units
•
Maintenance: 10-20 unit(s)/kg/h IV continuous infusion, capped at 1,250 units/hour (titrate per aPTT or anti-Xa according to institutional guidelines)
•
Maximum: 30,000 unit(s) per day
Titrate per aPTT (usual goal 1.5-2.5× baseline) or anti-Xa levels (usual goal 0.3-0.7 IU/mL) based on institutional guidelines. Consider favoring anti-Xa level monitoring in patients with obesity (e.g. > 120 kg), heparin resistance (e.g. requiring ≥ 35,000 units of heparin per day to achieve aPTT targets), lupus anticoagulant, DIC, direct thrombin inhibitor exposure (e.g., argatroban), as well as in pregnant patients.
Prevention and treatment
Prevention and treatment of thromboembolism in patients with AF
•
Start at: 60-80 unit(s)/kg IV once, capped at 5,000 units
•
Maintenance: 10-20 unit(s)/kg/h IV continuous infusion, capped at 1,250 units/hour (titrate per aPTT or anti-Xa according to institutional guidelines)
•
Maximum: 30,000 unit(s) per day
Titrate per aPTT (usual goal 1.5-2.5× baseline) or anti-Xa levels (usual goal 0.3-0.7 IU/mL) based on institutional guidelines. Consider favoring anti-Xa level monitoring in patients with obesity (e.g. > 120 kg), heparin resistance (e.g. requiring ≥ 35,000 units of heparin per day to achieve aPTT targets), lupus anticoagulant, DIC, direct thrombin inhibitor exposure (e.g., argatroban), as well as in pregnant patients.
Other off-label uses
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Treatment of cerebral venous thrombosis
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Treatment of VTE in patients with cancer
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Adjunctive treatment for non-ST elevation acute coronary syndrome (no prior anticoagulant therapy), during PCI
•
Adjunctive treatment for non-ST elevation acute coronary syndrome (received prior anticoagulant therapy), during PCI
Indications for use
Labeled indications
Adults
•
Treatment of arterial thromboembolism
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Treatment of VTE
•
Prevention and treatment of thromboembolism in patients with AF
•
Prevention of clotting, in patients undergoing blood transfusion
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Prevention of VTE, in patients undergoing open-heart surgery with cardiopulmonary bypass
Off-label indications
Adults
•
Treatment of cerebral venous thrombosis
•
Treatment of DIC in patients without acute hemorrhage (prothrombotic phenotype)
•
Treatment of VTE in patients with cancer
•
Adjunctive treatment for STEMI, in patients undergoing fibrinolytic therapy
•
Adjunctive treatment for STEMI, in patients undergoing PCI
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Adjunctive treatment for non-ST elevation acute coronary syndrome (no prior anticoagulant therapy), in patients undergoing PCI
•
Adjunctive treatment for non-ST elevation acute coronary syndrome (received prior anticoagulant therapy), in patients undergoing PCI
•
Adjunctive treatment for non-ST elevation acute coronary syndrome, before PCI
•
Prevention of thromboembolism in patients with AF, in patients undergoing cardioversion
Safety risks
Contraindications
Hypersensitivity to heparin or its components or pork products
•
Use in patients with documented hypersensitivity to heparin only in clearly life-threatening situations.
History of heparin-induced thrombocytopenia
Severe thrombocytopenia
Unavailability of coagulation monitoring
•
Do not use heparin when coagulation tests cannot be performed at appropriate intervals to monitor coagulation parameters in patients receiving full-dose heparin.
Uncontrolled active bleeding
•
Do not use heparin in patients with uncontrolled active bleeding, except in DIC.
Warnings and precautions
Decreased platelet count
•
Maintain a high level of suspicion, as thrombocytopenia can occur with the use of heparin. Obtain platelet counts before and periodically during therapy. Monitor blood coagulation tests in patients on full-dose heparin to adjust the dose.
Gasping syndrome
•
Use caution in infants, as heparin sodium vials contain benzyl alcohol preservative.
Hemorrhage
•
Use caution in patients at high risk of hemorrhage, including CVDs (subacute bacterial endocarditis, severe hypertension), perioperative states (during or immediately after lumbar puncture, spinal anesthesia, or major surgery, especially involving the brain, spinal cord, or eye), hematologic conditions (hemophilia, thrombocytopenia, vascular purpuras), hereditary antithrombin III deficiency treated with antithrombin III therapy, peptic ulcer disease, continuous tube drainage of the stomach or small intestine, liver disease with impaired hemostasis, and menstruation. Reduce heparin dose during concomitant treatment with antithrombin III.
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Avoid using heparin in major bleeding, except when the benefits outweigh the risks.
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Use caution in older patients, especially women.
Heparin resistance
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Maintain a high level of suspicion, as heparin resistance may occur in patients with fever, thrombosis, thrombophlebitis, infections with thrombosing tendencies, myocardial infarction, cancer, antithrombin III deficiency, and following surgery. Closely monitor coagulation tests.
Increased serum potassium
•
Use caution in patients with diabetes mellitus, CKD, metabolic acidosis, elevated serum potassium levels, or taking potassium-sparing drugs. Monitor potassium levels in at-risk patients.
Increased serum transaminases
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Maintain a high level of suspicion, as heparin has been associated with elevated levels of serum transaminases.
Specific populations
Renal impairment
eGFR 0-90 mL/min/1.73 m²
•
Use acceptable. No dose adjustment required. Monitor for hyperkalemia.
Renal replacement therapy
Any modality
•
Use acceptable. No dose adjustment required.
Hepatic impairment
Any severity
•
Use with caution.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: C
•
Use only if benefits outweigh potential risks.
Breastfeeding
Use only if benefits outweigh potential risks.
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Use preservative-free heparin formulations.
Unknown amount excreted in breastmilk.
Unknown drug levels in breastfed infants.
Adverse reactions
Very common > 10%
•
Bleeding, ↓ platelet count
Common 1-10%
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Heparin-induced thrombocytopenia
Unknown frequency
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Adrenal hemorrhage, adrenal insufficiency, ovarian hemorrhage, retroperitoneal hemorrhage, osteoporosis, histamine-like reactions, asthma, anaphylactoid reactions, hematemesis, gastrointestinal bleeding, hematuria, fever, chills, urticaria, rhinitis, tearing, headache, nausea, vomiting, plantar itching, ↑ serum transaminases, hair loss, priapism, ↑ serum cholesterol, ↑ serum potassium
Interactions
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