Caution- PL <80,000/cmm, uncontrolled active bleeding (except DIC), peptic ulcer, recent cerebral hemorrhage, severe hypertension, esophagealvarices, Recent neuro/eye surgery, spinal/epidural anaesthesia planned.
Hepatic correction, W/F HIT, hemorrhage, osteoporosis.
Discontinuation for 2-3hrs, normalizes blood clotting.
Reversal of effect can be done of protamine
IV Dosing: Initial bolus- 60 Units/kg (max- 5000 units) and start infusion as 14 units/kg/hr, then monitor APTT 6hrly, untill consecutive 1 APPT values are within therapeutic range. Later monitor once a week. Monitor CBC once in 2 days (for HIT)

APTT (Sec)	Bolus (Units)	Infusion rate
<40	3000	Increase 3U/kg/hr
40-50	2000	Increase 2U/kg/hr
51-59	None	Increase 1U/kg/hr
60-94	None	No change
95-104	None	Decrease 1U/kg/hr
105-114	Hold for 30min	Decrease 2U/kg/hr
>114	Hold for 1hr	Decrease 3U/kg/hr

Enoxaparin

Prophylaxis- 60mg OD- SC
Therapeutic- 60mg- BD- SC

1 mg/kg SC- BD

More predictable effect compared to heparin.
Renal correction, W/F hemorrhage, decreased platelet count, contraindicated in major active bleed, ITP,
Caution:spinal/ epidural anaesthesia planned, Peptic ulcer, recent brain/spinal/eye surgery, uncontrolled hypertension, diabetic retinopathy

Fondaparinux

Prophylaxis: 2.5mg-SC- OD
Therapeutic- 7.5mg- SC-OD

W/F hemorrhage,
contraindicated in major active bleed, ITP,
Caution:spinal/ epidural anaesthesia planned, Peptic ulcer, recent brain/spinal/eye surgery, uncontrolled hypertension, diabetic retinopathy

Warfarin

5mg- OD- HS- 2hrs after food.
Adjust dose as per INR

0.05- 0.34mg/kg- OD
Adjust dose as per INR

Contraindicated in pregnancy, blood dyscrasia, recent CNS/eye surgery, Caution: Bleeding disorder, peptic ulcer, CVA, Avoid alcohol, Avoid trauma.

Prolonged PT with or without bleeding- Refer “Other acquired coagulation disorders”

Acenocoumarol

1-8 mg. Adjust dose based on INR

Contraindicated in pregnancy, blood dyscrasia, recent CNS/eye surgery, Caution: Bleeding disorder, peptic ulcer, CVA, Avoid alcohol, Avoid trauma

Prolonged PT with or without bleeding- Refer “Other acquired coagulation disorders”

Rivaroxaban

15mg- BD for 21 days then 20mg OD- PO

Reduce dose if creatinine is high, W/F- Bleeding, avoid spinal and epidural anasthesia, avoid NSAIDs
Monitoring is not necessary.
Antidote is not easily available, if bleeding(Can try FFP/ Prothrombin complex concentrates hemodialysis and Factor 7a)

Antidote recently approved is andexanetalfa

Apixaban

2.5-5mg- BD

Reduce dose if creatinine is high, W/F- Bleeding, avoid spinal and epidural anasthesia, avoid NSAIDs
Monitoring is not necessary.
No antidote if bleeding(Can try FFP/ Prothrombin complex concentrates hemodialysis and Factor 7a)

Antidote recently approved is andexanetalfa

Dabigatran

150mg- BD

W/F- Bleeding, avoid spinal and epidural anasthesia, avoid NSAIDs
Monitoring is not necessary.
Idarucizumab is antidote if bleeding. It is monoclonal antibody fragment that binds to Dabigatran.

Aspirin

75mg-OD - PO

Contraindication- Creatinine clearance <10ml, GI ulcers, bleeding diathesis, reduced platelet count, children with fever, G6PD deficiency.
W/F bronchospasm, GI bleed, hepatotoxicity, tinnitus

Clopidogrel

75mg-OD - PO

Contraindication- Active bleed

Tranexamic acid

500-1000mg- TID- IV/PO

Contraindictaed if hematuria, DIC
W/F thrombosis and rhyabdomyolysis
Decrease dose in cardiac, renal and hepatic disease

Factor VIIa

5mg-(90microgm/kg) every 2 hrs, till bleeding stops

No major side effects/ contraindication

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