NICE COVID-19 rapid guideline NG200: vaccine-induced thrombocytopenia and thrombosis (VITT) (29 July 2021). This is an evolving area, check the NICE website for the latest guidance. Treatment is on the recommendation of a specialist involving a clinical haematologist. Heparins should be avoided. Please see here

Heparins

Dalteparin sodium

• Injection syringe 12,500units/1ml (2,500units/0.2ml)
• Injection syringe 25,000units/1ml (5,000units/0.2ml), (7,500units/0.3ml), (10,000units/0.4ml),(12,500units/0.5ml), (15,000units/0.6ml), (18,000units/0.72ml)
• Injection amp 2,500units/1ml (10,000units/4ml), 25,000units/1ml, (100,000units/4ml)
• Injection graduated syringe 10,000units/1ml

Notes

1. Dose adjustments are generally unnecessary for obesity or low body weight.
2. Reduce dose of dalteparin by 50% if eGFR less than 20ml/min.

Clexane

(Enoxaparin)

• Pre-filled syringe 2,000units (20mg), 4,000units (40mg), 6,000units (60mg), 8,000units (80mg), 10,000units (100mg)
• Multidose vial 30,000units (300mg)
• Clexane Forte pre-filled syringe 12,000units (120mg), 15,000units (150mg)

Notes

1. Prescribe by brand. Biological medicines (including biosimilar medicines) must be prescribed by brand name and the brand name specified on the prescription should be dispensed in order to avoid inadvertent switching, to prevent confusion and to ensure continuity of supply for patients. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.
2. Refer to the BNF or manufacturer's Summary of Product Characteristics (SPC) for dosing regimens
3. Following discharge from hospital, the administration time of enoxaparin may be moved by a maximum of 4 hours to facilitate administration at a convenient regular time by primary care practitioners.

Inhixa

(Enoxaparin)

• Pre-filled syringe 2,000units (20mg), 4,000units (40mg), 6,000units (60mg), 8,000units (80mg), 10,000units (100mg), 12,000units (120mg), 15,000units (150mg)

Indications

• Prophylaxis of venous thromboembolic disease
• Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE)
• Acute coronary syndrome (hospital only)
• Prevention of clotting in extracorporeal circuits (hospital only)

Notes

1. Prescribe by brand. Biological medicines (including biosimilar medicines) must be prescribed by brand name and the brand name specified on the prescription should be dispensed in order to avoid inadvertent switching, to prevent confusion and to ensure continuity of supply for patients. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.
2. Refer to the BNF or manufacturer's Summary of Product Characteristics (SPC) for dosing regimens
3. For an instructional video on the administration of Inhixa and the activation of the PREVENTIS needle shielding system, please click here
4. Following discharge from hospital, the administration time of enoxaparin may be moved by a maximum of 4 hours to facilitate administration at a convenient regular time by primary care practitioners

Tinzaparin sodium

• Pre-filled syringe 2,500units (0.25ml), 3,500units (0.35ml), 4,500units (0.45ml)

Notes

1. Tinzaparin is included for the prevention of clotting in the extracorporeal circuit during haemodialysis in patients with chronic renal insufficiency only.

Unfractionated heparin

Heparin sodium

• Injection 1,000units/1ml, 5,000units/1ml, 25,000units/1ml

Notes

1. Monitor APTR and adjust as advised by the trust anticoagulation protocol.
2. Although a low molecular weight heparin (LMWH) is generally preferred for routine use, a LMWH may not be suitable in the following scenarios:
   1. Severe renal dysfunction (eGFR less than 20mL/min)
   2. Massive DVT/PE
   3. Where extremely rapid onset is deemed appropriate
   4. Where there is a high risk of haemorrhage that may require rapid reversal

Unfractionated heparin may be appropriate in these circumstances, but close laboratory and clinical monitoring is essential.

Hirudins

Bivalirudin

• Injection powder for reconstitution 250mg vial

Notes

1. See NICE TA230 Bivalirudin for the treatment of ST-segment-elevation myocardial infarction (July 2011)

Heparin flushes

Epoprostenol

• Infusion 500micrograms, 1.5mg

Notes

1. Epoprostenol is a potent vasodilator and therefore its side-effects include flushing, headache and hypotension.

Fondaparinux

Fondaparinux

• Injection pre-filled syringe 2.5mg

Notes

1. Fondaparinux is included in the formulary for treatment of acute coronary syndrome (ACS)