Lepirudin Dosage

Usual Adult Dose for Thrombocytopenia Drug Induced

Heparin-induced thrombocytopenia:
Initial dose: 0.4 mg/kg IV (max 44 mg) slowly (over 15 to 20 seconds) followed by 0.15 mg/kg/hr IV (max 16.5 mg/hr) continuous infusion for 2 to 10 days or longer if clinically needed.

Renal Dose Adjustments

In all renally compromised patients, the loading dose should be reduced to 0.2 mg/kg (max. 22 mg).

Infusion rates:
CrCl less than 15 mL/min: avoid or stop infusion.

CrCl 15-29 mL/min: 0.0225 mg/kg/hr

CrCl 30-44 mL/min: 0.045 mg/kg/hr

CrCl 45-60 mL/min: 0.075 mg/kg/hr

CrCl greater than 60 mL/min: 0.15 mg/kg/hr

Liver Dose Adjustments

Serious liver injury (e.g., liver cirrhosis) may enhance the anticoagulant effect of lepirudin due to coagulation defects secondary to reduced generation of vitamin K-dependent coagulation factors.

Dose Adjustments

If the patient is on concomitant thrombolytic therapy, decrease the bolus dose to 0.2 mg/kg and reduce the infusion to 0.1 mg/kg/hr.

Precautions

The risk of hemorrhage is increased when lepirudin is administered with other anticoagulant agents, antiplatelet agents, and/or thrombolytics.

Antihirudin antibodies form in 40% to 60% of HIT patients treated with lepirudin, which may increase the anticoagulant effect of lepirudin.

Safety and effectiveness have not been established in pediatric patients (less than 18 years of age).

Dialysis

If dialysis patients have received lepirudin, additional IV bolus doses of 0.1 mg/kg every other day may be administered only if the aPTT ratio falls below the lower therapeutic limit of 1.5. Continuous infusion therapy in dialysis patients is contraindicated.

Other Comments

When switching from IV lepirudin to oral warfarin anticoagulant therapy, titrate the lepirudin to an aPTT ratio of 1.5 before initiating warfarin therapy. As soon as the patient's INR reaches 2, discontinue the lepirudin.

It should be noted that the result of another study showed that lepirudin can elevate the INR in the absence of warfarin. For the transition to long-term oral anticoagulation and during lepirudin and warfarin cotherapy, an elevated INR (i.e. above 2) may be required in order to achieve an INR of 2 to 3 when lepirudin is discontinued.

Initial bolus solution should be a 5 mg/mL concentration.

Activated partial thromboplastin time (aPTT) should be obtained 4 hours after the start of treatment, then at least daily during treatment and 4 hours after each dosage adjustment. If the aPTT is above the target range (1.5 to 2.5 x baseline), stop the lepirudin infusion for 2 hours and then restart at an infusion rate reduced by 50% with no bolus. If the aPTT is below the target range, increase the infusion rate in 20% increments.

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Further information

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