Unfractionated Heparin

Aka: Unfractionated Heparin, Heparin

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II. Indications

  1. Venous Thromboembolism (DVT, PE) prevention and treatment
  2. Acute Coronary Syndrome
  3. Acute Limb Ischemia

III. Mechanism

  1. See Intrinsic Clotting Pathway
  2. Heparin binds to, and potentiates Antithrombin III (AT III)
    1. Antithrombin III binds to an inhibits Factor Xa
    2. Results in decreased Thrombin (and ultimately Fibrin) formation

IV. Dosing: Prophylactic for DVT Prevention

  1. Heparin 5000 Units SQ every 8-12 hours

V. Dosing: Adult High Intensity Dosing by Weight based Calculations (PE/DVT)

  1. Measure
    1. Total body weight (TBW) in kilograms
    2. Height in inches
  2. Calculate Lean Body Weight (LBW) in kilograms
    1. Male: 50 + 2.3 x (height in inches - 60)
    2. Female: 45 + 2.3 x (height in inches -60)
  3. Calculate Dosing Weight
    1. Non-Obese
      1. Dosing Weight (kg): TBW above
    2. Obese (TBW > 1.4 x LBW)
      1. Dosing Weight (kg): (0.4 x TBW) + LBW
  4. Calculate Heparin starting doses
    1. Monitor with aPTT
    2. Bolus: 80 Units/kg
      1. Maximum: 10,000 units
      2. Round to nearest 100 units
    3. Maintenance: 18 Units/kg/hour
      1. Round to nearest 50 units per hour
  5. Alternative Protocol in an unmonitored setting (off label)
    1. Load 333 units/kg SC
    2. Maintenance 250 units/kg SC every 12 hours
    3. Maximum weight 100 kg
  6. Pregnancy
    1. Continue above protocol for at least 5 days of full Anticoagulation
    2. Next, administer 10,000 units SC every 8 to 12 hours adjusting based on aPTT target 1.5 to 2.5x normal control
    3. Transition back to Heparin infusion, at least 24 hours before delivery

VI. Protocol: Adult High Intensity Therapeutic Dosing Nomogram Using PTT (PE/DVT)

  1. Alternatively, use Anti-Xa Level for monitoring
  2. Protocol follows high intensity starting dose as above
  3. aPTT <35 seconds (<1.2x normal control)
    1. Give 80 units/kg IV bolus
    2. Increase infusion rate by 4 units/kg/hour
    3. Recheck aPTT in 6 hours
  4. aPTT 35 to 45 seconds (1.2 to 1.5x normal control)
    1. Give 40 units/kg IV bolus
    2. Increase infusion rate by 2 units/kg/hour
    3. Recheck aPTT in 6 hours
  5. aPTT 46 to 70 seconds (1.5 to 2.3x normal control)
    1. No change in dosing
    2. Recheck aPTT on the next morning
  6. aPTT 71 to 90 seconds (2.3 to 3.0x normal control)
    1. Decrease maintenance rate by 2 units/kg/hour
    2. Recheck aPTT in 6 hours
  7. aPTT >90 seconds
    1. Stop Heparin infusion for 60 minutes
    2. Decrease maintenance rate by 3 units/kg/hour
    3. Recheck aPTT in 6 hours

VII. Dosing: Child High Intensity Dosing by Weight based Calculations (PE/DVT)

  1. Monitor and adjust infusion based on aPTT or anti-Xa Levels
  2. Starting Protocol 1 (FDA approved package insert)
    1. Bolus 50 units/kg IV
    2. Maintenance: 25 Units/kg/hour
  3. Starting Protocol 2 (off label)
    1. Bolus 75 units/kg IV over 10 minutes
    2. Maintenance: 20 Units/kg/hour
      1. Start 28 units/kg/hour if age <1 year old

VIII. Dosing: Adult Low Intensity Dosing by Weight-Based Calculations (Acute Coronary Syndrome)

  1. Monitor and adjust infusion based on aPTT (1.5 to 2x normal) or anti-Xa Levels
  2. Load 60 units/kg IV (up to 4000 units IV)
  3. Infuse 12 units/kg/hour

IX. Labs: Therapeutic Dosing Initial (before Heparin)

  1. Partial Thromboplastin Time (aPTT)
  2. Anti-Xa Level (if used instead of aPTT)
  3. ProTime (INR)
  4. Complete Blood Count (CBC) with Platelet Count

X. Labs: Therapeutic Dosing Recurring Labs

  1. Partial Thromboplastin Time (aPTT)
    1. 6 hours after bolus and then per nomogram
  2. Anti-Xa Level
    1. May be used as an alternative to aPTT monitoring
  3. Platelets
    1. Every 3 days
    2. Minimum: 150,000

XI. Adverse Effects

  1. Bleeding complications
  2. Heparin Induced Thrombocytopenia

XII. Drug Interactions

  1. Medications that increase bleeding risk
    1. Aspirin
    2. Platelet ADP Receptor Antagonist (e.g. Clopidogrel)
    3. NSAIDs (e.g. Ibuprofen, Indomethacin)
    4. Other Anticoagulants (e.g. DOACs, Warfarin)
    5. Glycoprotein IIB/IIIA Inhibitor
    6. Miscellaneous Antibiotics (e.g. some Penicillins, Cephalosporins)
    7. Valproic Acid
    8. AntiThyroid Medications (Methimazole, Propylthiouracil)
    9. Antimalarials (Chloroquine, Hydroxychloroquine)
  2. Medications that decrease Heparin efficacy
    1. Digoxin
    2. Tetracycline
    3. Antihistamines

XIII. Management: Reversal

  1. Protamine sulfate

XIV. Resources

  1. Heparin Injection Solution (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=85b4a714-70cd-42ec-97ce-fd8515b2392e

XV. References

  1. Hamilton (2020) Tarascon Pocket Pharmacopoeia
  2. Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 83
  3. Warnock (2022) Heparin, StatPearls, Treasure Island, FL
    1. https://www.ncbi.nlm.nih.gov/books/NBK538247/

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Related Studies

Cost: Medications

heparin (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
HEPARIN SODIUM 10,000 UNIT/ML VIAL Generic $1.79 per ml
HEPARIN SODIUM 5,000 UNIT/ML VIAL Generic $1.30 per ml
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

Ontology: Heparin (C0019134)

Definition (NCI) A sulfur-rich glycosaminoglycan with anticoagulant property. Heparin binds to antithrombin III to form a heparin-antithrombin III complex. The complex binds to and irreversibly inactivates thrombin and other activated clotting factors, such as factors IX, X, XI, and XII, thereby preventing the polymerization of fibrinogen to fibrin and the subsequent formation of clots.
Definition (NCI_NCI-GLOSS) A substance that slows the formation of blood clots. Heparin is made by the liver, lungs, and other tissues in the body and can also made in the laboratory. Heparin may be injected into muscle or blood to prevent or break up blood clots. It is a type of anticoagulant.
Definition (SPN) Enzyme preparations are products that are used in the histopathology laboratory for the following purposes: (1) To disaggregate tissues and cells already in established cultures for preparation into subsequent cultures (e.g., trypsin); (2) To disaggregate fluid specimens for cytological examination (e.g., papain for gastric lavage or trypsin for sputum liquefaction); (3) To aid in the selective staining of tissue specimens (e.g., diastase for glycogen determination).
Definition (MSH) A highly acidic mucopolysaccharide formed of equal parts of sulfated D-glucosamine and D-glucuronic acid with sulfaminic bridges. The molecular weight ranges from six to twenty thousand. Heparin occurs in and is obtained from liver, lung, mast cells, etc., of vertebrates. Its function is unknown, but it is used to prevent blood clotting in vivo and vitro, in the form of many different salts.
Definition (CSP) poly(glucosamine sulfate-glucuronic acid); endogenous mucopolysaccharide with antithrombin and lipotropic activities; USP injection is used as an anticoagulant.
Concepts Pharmacologic Substance (T121) , Biologically Active Substance (T123) , Carbohydrate (T118)
MSH D006493
SnomedCT 372877000, 84812008, 96382006
LNC LP15998-5, LP16002-5, MTHU003766, MTHU015164
English Heparin, Heparinic Acid, heparin preparations (medication), heparin preparations, Heparin [Chemical/Ingredient], Heparin, Unfractionated, Unfractionated Heparin, unfractionated heparin, heparin unfractionated, heparins, heparin, Heparin.unfractionated, Unfractionated heparin, Heparin (product), Heparin (substance), Unfractionated heparin (substance), HEPARIN
Swedish Heparin
Czech heparin
Finnish Hepariini
Italian Acido eparinico, Eparina non frazionata, Eparina
Russian GEPARIN, AL'FA-GEPARIN, GEPARINOVAIA KISLOTA, АЛЬФА-ГЕПАРИН, ГЕПАРИН, ГЕПАРИНОВАЯ КИСЛОТА
Japanese α-ヘパリン, ヘパリン, アルファヘパリン
Croatian HEPARIN
Polish Heparyna
Spanish heparina (producto), heparina (sustancia), heparina no fraccionada (sustancia), heparina no fraccionada, heparina, Heparina, Ácido Heparínico
French Héparine
German Heparin, Heparinsäure
Portuguese Ácido Heparínico, Heparina
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Unfractionated Heparin [EPC] (C2825026)

Concepts Pharmacologic Substance (T121)
English Unfractionated Heparin [EPC], Unfractionated Heparin
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Pharmacology

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