Generic Name: Dalteparin Sodium
Chemical Name: Heparin, sodium salt
CAS Number: 9041-08-1
Medically reviewed on October 23, 2017
- Spinal/Epidural Hematoma Risk
Epidural or spinal hematomas and neurologic injury, including long-term or permanent paralysis, associated with concurrent use of low molecular weight heparins (LMWHs) or heparinoids and neuraxial (spinal/epidural) anesthesia or spinal puncture.1 35 77
Optimal timing between administration of dalteparin and neuraxial procedures not known.1
Consider potential benefits versus risks of spinal or epidural anesthesia or spinal puncture in patients receiving or being considered for thromboprophylaxis with anticoagulants.1 35 (See Spinal/Epidural Hematomas under Cautions.)
Uses for Fragmin
Unstable Angina and Non-ST-Segment-Elevation MI (NSTEMI)
Used to reduce the risk of acute cardiac ischemic events (death, MI) in patients with unstable angina or NSTEMI (i.e., non-ST-segment-elevation acute coronary syndromes [NSTE ACS]).1 51 52 53 54 66 103 104 991 Used concurrently with aspirin and/or other standard therapy (e.g., nitrates, β-adrenergic blockers, clopidogrel, platelet glycoprotein [GP] IIb/IIIa-receptor inhibitors).1 51 52 53 54 66 103 104 991
If an LMWH is selected for initial parenteral anticoagulation in patients with NSTE ACS, the American Heart Association (AHA) and American College of Cardiology Foundation (ACCF) recommend the use of enoxaparin; other parenteral anticoagulants with established efficacy include heparin, bivalirudin (only in patients being managed with an early invasive strategy), and fondaparinux.1100
Thromboprophylaxis in Hip-Replacement, Knee-Replacement, or Hip-Fracture Surgery
ACCP recommends routine thromboprophylaxis with a pharmacologic (e.g., LMWH) and/or mechanical method in all patients undergoing major orthopedic surgery because of high risk of postoperative venous thromboembolism; continue thromboprophylaxis for at least 10–14 days, and possibly for up to 35 days after surgery.1003
Several antithrombotic agents (e.g., LMWHs, fondaparinux, low-dose heparin, warfarin, aspirin) are recommended by ACCP for pharmacologic prophylaxis during major orthopedic surgery.1003 When selecting an appropriate thromboprophylaxis regimen, consider factors such as relative efficacy, safety, logistics, and compliance.1003
Thromboprophylaxis in General/Abdominal Surgery
ACCP recommends pharmacologic (e.g., LMWHs) and/or nonpharmacologic/mechanical (e.g., intermittent pneumatic compression) methods of thromboprophylaxis in patients undergoing general surgery, including abdominal, GI, gynecologic, and urologic surgery, according to the patient’s risk of thromboembolism and bleeding.1002 In general, pharmacologic prophylaxis is recommended in patients with high (and possibly moderate) risk of venous thromboembolism who do not have a high risk of bleeding, while mechanical methods are suggested in patients who require thromboprophylaxis but have a high risk of bleeding.1002
If pharmacologic prophylaxis is used in patients undergoing general surgery, ACCP states that an LMWH or low-dose heparin is preferred.1002
Because risk of venous thromboembolism is particularly high in patients undergoing abdominal or pelvic surgery for cancer, extended (4 weeks) prophylaxis with an LMWH is recommended in such patients.1002
ACCP states that the recommendations for use of antithrombotic agents in general surgery patients can be applied to patients undergoing bariatric, vascular, and plastic/reconstructive surgery.1002
Medical Conditions Predisposing to Thromboembolism
In general, pharmacologic thromboprophylaxis recommended only in patients considered to be at high risk of venous thromboembolism.1001
ACCP recommends anticoagulant prophylaxis (e.g., LMWH) in acutely ill, hospitalized medical patients at increased risk of thrombosis who are not actively bleeding and do not have an increased risk of bleeding.1001 Continued thromboprophylaxis suggested for 6–21 days until full mobility is restored or until hospital discharge, whichever comes first.1001
Use of LMWHs also suggested by ACCP for pharmacologic thromboprophylaxis in critically ill patients (e.g., those in an intensive care unit [ICU]) who are not actively bleeding and do not have risk factors for bleeding.1001
Risk of venous thromboembolism particularly high in patients with cancer.1001 Use of LMWH prophylaxis suggested by ACCP in cancer outpatients with solid tumors who have additional risk factors for thromboembolism provided risk of bleeding is low.1001
Thromboprophylaxis in Cardiac Surgery
Mechanical methods of prophylaxis generally recommended in patients undergoing cardiac surgery; however, ACCP states that an LMWH may be considered for thromboprophylaxis in cardiac surgery† patients with a complicated postoperative course.1002
Thromboprophylaxis in Thoracic Surgery
Thromboprophylaxis in Neurosurgery
LMWHs have been used for prevention of venous thromboembolism in patients undergoing craniotomy†; however, benefits of such prophylaxis may be outweighed by possible increased risk of intracranial hemorrhage.1002 ACCP states that LMWH prophylaxis may be considered in patients at very high risk of thromboembolism (e.g., those undergoing craniotomy for malignant disease) once adequate hemostasis established and risk of bleeding decreases.1002
Thromboprophylaxis with LMWHs also may be considered in high-risk patients undergoing spinal surgery† (e.g., those with malignancy or those undergoing surgery with a combined anterior-posterior approach) once adequate hemostasis established and risk of bleeding decreases.1002
Thromboprophylaxis in Trauma
LMWHs may be used for thromboprophylaxis in patients with major trauma†.1002 For major trauma patients at high risk of venous thromboembolism, including those with acute spinal cord injury, traumatic brain injury, or spinal surgery for trauma, ACCP suggests use of both a pharmacologic and mechanical method of prophylaxis unless contraindications exist.1002
Extended Treatment of Acute Venous Thromboembolism in Cancer Patients
Used for extended (6 months' duration) treatment of symptomatic DVT and/or PE in patients with cancer to reduce recurrence (secondary prevention) of venous thromboembolism.1 Manufacturer states that safety and efficacy of treatment durations >6 months not established.1
Acute Venous Thromboembolism
Manufacturer states that dalteparin not indicated for the acute treatment of venous thromboembolism;†1 however, has been recommended by ACCP as an appropriate option for initial treatment of acute proximal DVT and/or PE.1005
LMWHs or fondaparinux generally preferred over heparin for initial treatment of acute venous thromboembolism; however, heparin may be preferred in patients with renal impairment.1005 IV heparin also may be preferred over LMWHs in patients with PE in whom thrombolytic therapy is being considered or if there is concern about adequate sub-Q absorption.1005
For long-term anticoagulant therapy, warfarin generally preferred in patients without cancer; however, ACCP suggests use of an LMWH in patients with cancer because of a possible reduced response to warfarin.1005
Continue anticoagulant therapy for ≥3 months and possibly longer depending on individual clinical situation.1005
Venous Thromboembolism in Pediatric Patients
An LMWH has been used for treatment and secondary prevention of venous thromboembolism in pediatric patients†; venous thromboembolism usually occurs secondary to an identifiable risk factor (e.g., presence of central venous access device in such patients).1013
Recommendations regarding use of antithrombotic therapy in children generally based on extrapolation from adult guidelines.1013
ACCP recommends an LMWH or heparin for both initial and ongoing treatment of venous thromboembolism in children.1013 Potential advantages of an LMWH over heparin include reduced need for monitoring, lack of drug or dietary interactions, reduced risk of heparin-induced thrombocytopenia (HIT), and possible reduced risk of osteoporosis.1013
In children with central venous catheter-related thromboembolism, ACCP recommends removal of catheter if no longer functioning or required; at least 3–5 days of therapeutic anticoagulation is suggested prior to removal.1013 If such catheters must remain in place, ACCP suggests anticoagulant therapy until catheter is removed.1013
Treatment of Superficial Vein Thrombosis
LMWHs also have been used for spontaneous superficial vein thrombosis (superficial thrombophlebitis)†; ACCP suggests use of prophylactic dosages for 45 days in patients with superficial vein thrombosis of ≥5 cm in length.1005
Treatment of Renal Vein Thrombosis
Although use of anticoagulant therapy for renal vein thrombosis† (the most common cause of spontaneous venous thromboembolism in neonates) is controversial, LMWHs are suggested by ACCP as a possible treatment option.1013
Thromboprophylaxis in Acute Ischemic Stroke
Heparin anticoagulants (i.e., LMWHs or heparin) have been used for thromboprophylaxis in selected patients with acute ischemic stroke†; those with additional risk factors for venous thromboembolism are more likely to benefit from such prophylaxis.1009 1017
ACCP suggests thromboprophylaxis with an LMWH, sub-Q heparin, or intermittent pneumatic compression in patients with acute ischemic stroke† and restricted mobility; LMWH is preferred over heparin.1009
Prophylactic-dose heparin (heparin or an LMWH) usually initiated within 48 hours of onset of stroke and is continued throughout hospital stay until patient regains mobility; do not administer within the first 24 hours after thrombolytic therapy.1009
LMWHs also recommended by ACCP as an option for initial management of acute arterial ischemic stroke in children† until dissection and embolic causes have been excluded.1013 If arterial ischemic stroke is associated with dissection or a cardioembolic origin, continued anticoagulant therapy suggested.1013
Thromboembolism During Pregnancy
Used during pregnancy for prevention and treatment of venous thromboembolism† and for prevention and treatment of systemic embolism associated with mechanical heart valves†.138 996 1012 (See Prevention and Treatment of Thromboembolism During Pregnancy under Dosage and Administration.)
LMWHs (rather than heparin or warfarin) are recommended by ACCP for prevention and treatment of thromboembolism during pregnancy.1012
In pregnant women with an acute venous thromboembolic event†, ACCP recommends an LMWH for initial treatment and secondary prevention throughout the remainder of the pregnancy.1012 To prevent recurrence, postpartum anticoagulation (for ≥6 weeks and for a total duration of ≥3 months) is suggested.1012
In general, thromboprophylaxis (e.g., with an LMWH) is suggested during the antepartum period only in pregnant women who have a history of thromboembolism† and are considered to be at moderate to high risk of recurrent events (e.g., those with a single episode of unprovoked venous thromboembolism, pregnancy- or estrogen-related venous thromboembolism, history of multiple unprovoked events).1012
Postpartum thromboprophylaxis† for 6 weeks suggested in all pregnant women with a prior venous thromboembolic event; an LMWH (in prophylactic or intermediate dosages) or warfarin (INR 2–3) may be used for such prophylaxis.1012
ACCP suggests antepartum and postpartum prophylaxis with an LMWH in some pregnant women with high-risk hereditary thrombophilias† (e.g., homozygous genetic mutations for factor V Leiden or prothrombin G20210A) who have not experienced a prior venous thromboembolic event, but have a family history of thromboembolism.1012
Discontinue LMWH therapy ≥24 hours prior to induction of labor or cesarean section (or expected time of neuraxial anesthesia) to avoid an unwanted anticoagulant effect on fetus.1012
Cardioversion of Atrial Fibrillation/Flutter
As an alternative to prolonged anticoagulation (e.g., usually with warfarin) prior to cardioversion in patients with atrial fibrillation lasting >48 hours or of unknown duration, an LMWH (in therapeutic dosages) may be used at the time of transesophageal echocardiography (TEE), followed by cardioversion within 24 hours if no thrombus is detected.999 1007
In patients with atrial fibrillation of short duration (e.g., ≤48 hours), an LMWH (in therapeutic dosages) may be used at presentation, followed by immediate cardioversion.1007
In patients with hemodynamic instability who require urgent cardioversion, ACCP suggests administration of a parenteral anticoagulant (in therapeutic dosages) prior to cardioversion if possible; however, such anticoagulant therapy must not delay any emergency intervention.999 1007
Thromboprophylaxis in Patients with Prosthetic Heart Valves
ACCP suggests bridging anticoagulation (an LMWH in either prophylactic or therapeutic dosages or IV heparin in prophylactic dosages) during the early postoperative period after insertion of a mechanical heart valve in patients without bleeding risk, until an adequate response to warfarin is obtained.1008
Also may be used for bridging anticoagulation in patients with a mechanical heart valve in whom therapy with warfarin must be temporarily discontinued (e.g., those undergoing major surgery).1004
Treatment of Cerebral Venous Sinus Thrombosis
Reasonable to use full-dose LMWH rather than heparin for treatment of acute cerebral venous sinus thrombosis during pregnancy.1017 Prophylaxis with an LMWH during pregnancy and the postpartum period is reasonable in women with history of cerebral venous sinus thrombosis.1017
Recommended by ACCP as an option for initial and follow-up anticoagulation in children with cerebral venous sinus thrombosis† without substantial intracranial hemorrhage.1013 Also has been suggested for use in children with substantial intracranial hemorrhage.1013
Perioperative Antithrombotic Prophylaxis
ACCP suggests use of an LMWH or IV heparin during temporary interruption of warfarin therapy (bridging anticoagulation†) in selected patients with venous thromboembolism, atrial fibrillation, or mechanical prosthetic heart valves undergoing surgery or other invasive procedures; use and type of bridging anticoagulation depend on patients' risk of developing thromboembolism without warfarin therapy.1004
In general, bridging anticoagulation is suggested in such patients who are considered to be at particularly high risk of venous thromboembolism without oral anticoagulant therapy.1004
Fragmin Dosage and Administration
Monitoring of anti-factor Xa levels may be helpful in high-risk groups, such as pregnant patients, patients with renal impairment, patients at extremes of weight, or if abnormal coagulation parameters or bleeding occurs during treatment.1 152
If an LMWH is used for anticoagulation in children, ACCP suggests that dosage be adjusted to a target anti-factor Xa level of 0.5–1 units/mL based on a sample taken 4–6 hours or 0.5–0.8 units/mL based on a sample taken 2–6 hours, following sub-Q administration.1013
Administer by deep sub-Q injection; do not give IM.1
Patient should be sitting or supine during administration.1
When injecting, insert entire length of needle at 45–90° angle.1 Administer injections into the U-shaped area around the navel, upper outer aspect of the thigh, or upper outer quadrangle of the buttock.1 Alternate injection sites daily.1 When injecting into area around the navel or the thigh, insert needle into a skin fold created by thumb and forefinger.1 Hold skin until needle is withdrawn.1
Injection is commercially available in prefilled syringes equipped with a 27-gauge ½-inch needle.1
Unstable Angina and NSTEMI
120 units/kg every 12 hours (up to a maximum of 10,000 units every 12 hours) until patient is clinically stabilized, generally for 5–8 days.1 Concurrent aspirin therapy recommended in all patients unless contraindicated.1
Prevention of DVT and/or PE
Initiate therapy either preoperatively or postoperatively; several regimens are recommended by manufacturer.1
Preoperative start, evening before surgery: 5000 units 10–14 hours before surgery, followed by 5000 units 4–8 hours after surgery, or later if hemostasis has not been achieved.1
Preoperative start, day of surgery: 2500 units within 2 hours prior to surgery, followed by 2500 units 4–8 hours after surgery, or later if hemostasis has not been achieved.1
Postoperative start: 2500 units 4–8 hours after surgery, or later if hemostasis has not been achieved.1
Continue with 5000 units once daily throughout postoperative period (manufacturer states generally for 5–10 days, but up to 14 days has been well tolerated).1 ACCP recommends a minimum of 10–14 days of thromboprophylaxis, with extended prophylaxis suggested for up to 35 days on an outpatient basis.1003
Usual dosage: 2500 units initially,1 5 6 7 8 9 27 30 given 1–2 hours before surgery.1 6 8 9 19 21 Continue with 2500 units once daily throughout postoperative period, generally for 5–10 days.1 6 7 8 9 10 19 20 21
Patients undergoing abdominal surgery associated with a high risk of thromboembolism (e.g., surgery for malignancy): 5000 units, initiated on the evening prior to surgery, followed by daily administration of 5000 units throughout postoperative period.1 Alternatively, in patients with malignancy, may administer 2500 units 1–2 hours prior to surgery and repeat dose 12 hours later; follow with 5000 units daily throughout postoperative period, generally for 5–10 days.1 30 33
Extended prophylaxis (for up to 4 weeks) recommended by ACCP in patients undergoing abdominal or pelvic surgery for cancer.1002
Medical Conditions Predisposing to ThromboembolismSub-Q
Acute illness with severely restricted mobility: 5000 units once daily, generally for 12–14 days.1
Extended Treatment of Venous Thromboembolism in Cancer Patients
First 30 days of treatment: 200 units/kg (not to exceed total daily dosage of 18,000 units) once daily.1
Months 2–6 of treatment: Approximately 150 units/kg (not to exceed total daily dosage of 18,000 units) once daily.1
Safety and efficacy of treatment periods >6 months not established.1
Patients with thrombocytopenia: Reduce daily dosage by 2500 units in patients with platelet counts of 50,000–100,000/mm3 until platelet count recovers to ≥100,000/mm3.1 Discontinue therapy if platelet count <50,000/mm3 until platelet count recovers to >50,000/mm3.1
Prevention and Treatment of Thromboembolism During Pregnancy†
Treatment of acute venous thromboembolism: ACCP recommends 200 units/kg daily in 1 or 2 divided doses throughout the remainder of pregnancy; continue anticoagulation for ≥6 weeks postpartum (minimum total duration of 3 months).1012
Postpartum prophylaxis in patients with a prior venous thromboembolic event: Prophylactic (5000 units once daily) or intermediate (5000 units every 12 hours) dosage suggested.1012
Pregnant women receiving long-term coumarin anticoagulation (e.g., warfarin): An LMWH may be used throughout pregnancy in a weight-adjusted dosage (e.g., dalteparin sodium 100 units/kg twice daily or dalteparin sodium 200 units/kg daily) or 75% of a weight-adjusted dosage; resume long-term anticoagulation postpartum.1012
Primary prevention of venous thromboembolism in pregnant women with high-risk thrombophilias: Prophylactic (5000 units once daily) or intermediate (5000 units every 12 hours) dosage suggested.1012
Pregnant women with APLA syndrome: Antepartum administration of an LMWH in prophylactic dosages recommended by ACCP; combine with low-dose aspirin (75–100 mg daily).1012
Pregnant women with mechanical heart valves: ACCP recommends an LMWH throughout pregnancy or, alternatively, an LMWH until 13th week of pregnancy, substituting warfarin until close to delivery, then resuming LMWH therapy.1012 Dosage adjustment suggested to maintain manufacturer-recommended peak anti-factor Xa concentration 4 hours after dosing.1012 Resume usual long-term anticoagulation postpartum.1012 (See Patients with Mechanical Prosthetic Heart Valves under Cautions.)
To avoid an unwanted anticoagulant effect on the fetus during delivery, discontinue LMWH ≥24 hours prior to induction of labor or cesarean section.1012
Cardioversion of Atrial Fibrillation/Flutter†
For prevention of stroke and systemic embolism in patients undergoing cardioversion for atrial fibrillation or atrial flutter, use of full venous thromboembolism treatment dosages recommended.1007
Perioperative Antithrombotic Prophylaxis†
For bridging anticoagulation during temporary interruption of warfarin therapy in patients undergoing surgery or other invasive procedures, ACCP generally recommends therapeutic dosages of an LMWH (e.g., dalteparin sodium 100 units/kg twice daily or 200 units/kg once daily).1004
Unstable Angina or NSTEMI
Maximum 10,000 units every 12 hours.1
Patients with Cancer
Maximum total daily dose of 18,000 units.1
No specific dosage recommendations at this time.1
Use with caution in patients with severe renal insufficiency; monitor anti-factor Xa levels to determine appropriate dosage in such patients.1 152 ACCP suggests that dosage be reduced in patients with severe renal impairment (Clcr <30 mL/minute).1000
Careful attention to dosing intervals and concomitant medications (particularly antiplatelet drugs) is advised, particularly in geriatric patients with low body weight (<45 kg).1
Cautions for Fragmin
Active major bleeding.1
History of HIT with or without thrombosis.1
Known hypersensitivity to dalteparin, heparin, or pork products.1
Use for unstable angina or NSTEMI or prolonged prophylaxis of venous thromboembolism in patients undergoing neuraxial (epidural/spinal) anesthesia.1
Epidural or spinal hematoma reported with concurrent use of anticoagulants (e.g., LMWHs, heparinoids) and neuraxial (spinal/epidural) anesthesia or spinal puncture procedures.1 35 77 161 163 Such hematomas have resulted in neurologic injury, including long-term or permanent paralysis.1 161 (See Boxed Warning.)
Prior to performing a spinal or epidural procedure, determine whether a patient is receiving anticoagulants.161
Carefully consider the timing of spinal catheter placement and removal in relation to anticoagulant use, considering both dosage and pharmacokinetic properties (e.g., elimination half-life) of the anticoagulant.1 161
Assume that patients receiving dalteparin thromboprophylaxis prior to surgery have altered coagulation; administer first postoperative prophylactic dose (2500 units) 6–8 hours after surgery and second dose (2500 or 5000 units) no sooner than 24 hours after first dose.1
Insertion or removal of catheter is best performed when the anticoagulant effect of dalteparin is minimal (e.g., at least 12 hours after a low dosage [2500 or 5000 units once daily] or at least 24 hours after higher dosages [200 units/kg once daily or 120 units/kg twice daily]); optimal timing to achieve sufficiently low anticoagulant effect not known.1 Consider doubling these recommended time delays in patients with renal impairment.1
Frequently monitor for signs of neurologic impairment (e.g., midline back pain, numbness or weakness in lower limbs, bowel or bladder dysfunction).1 If spinal hematoma suspected, diagnose and treat immediately; consider spinal cord decompression even though it may not prevent or reverse neurologic sequelae.1
Other Warnings Related to Hemorrhage
Use with extreme caution in patients with an increased risk of hemorrhage.1 Such patients include those with bacterial endocarditis; congenital or acquired bleeding disorders; active ulceration and angiodysplastic GI disease; hemorrhagic stroke; or recent brain, spinal, or ophthalmologic surgery.1 Increased risk for hemorrhage in patients with thrombocytopenia, platelet defects, those treated concomitantly with platelet-aggregation inhibitors; patients with uncontrolled arterial hypertension; and those with a history of recent GI ulceration, diabetic retinopathy, renal dysfunction, or hemorrhage.1
Periodic CBCs, including platelet counts, and stool occult blood tests recommended.1 If abnormal coagulation parameters or bleeding should occur, may use anti-factor Xa levels to monitor anticoagulant effects of dalteparin.1
Patients with Mechanical Prosthetic Heart Valves
Valve thrombosis resulting in death (including maternal and fetal deaths) and/or requiring surgical intervention reported during thromboprophylaxis with another LMWH (enoxaparin) in some patients (including pregnant women) with mechanical prosthetic heart valves.101 107 108 109 110 111 112 113 114 115 996 Women with mechanical prosthetic heart valves are at higher risk for thromboembolism during pregnancy,112 132 133 134 138 139 and the manufacturer states that dalteparin has not been studied systematically in patients with prosthetic heart valves.102 (See Prevention and Treatment of Thromboembolism during Pregnancy under Dosage and Administration.)
Category B.1 Benzyl alcohol used as a preservative in multiple-dose vials of dalteparin may cross the placenta.1 67 Use caution when administering dalteparin in multiple-dose vials containing benzyl alcohol to pregnant women; use preservative-free formulations when possible.1 67
Multiple-dose vials contain benzyl alcohol as a preservative.1 Administration of injections preserved with benzyl alcohol to premature infants has, in large amounts, been associated with toxicity and fatal “gasping syndrome”.1 67 68 69 70 71 72
Possible increased risk of bleeding in geriatric patients; however, no substantial differences in safety relative to younger adults reported.1 Pay careful attention to dosing intervals and concomitant agents (particularly antiplatelet agents), particularly in geriatric patients with low body weight (<45 kg) and those predisposed to decreased renal function.1
Use with caution in patients with severe renal impairment; greater drug accumulation can be expected in such patients.1
Common Adverse Effects
Interactions for Fragmin
Increased risk of bleeding1
Use concomitantly with care1
Increased risk of bleeding1
Use concomitantly with care1
Increased risk of bleeding1
Use concomitantly with care1
Mean peak plasma levels of anti-factor Xa activity generally attained about 4 hours after a single sub-Q injection.1
40–60 mL/kg (based on anti-factor Xa activity).1
3–5 hours following sub-Q administration.1
Terminal half-life prolonged (to approximately 5.7 hours) in patients with chronic renal insufficiency requiring hemodialysis compared with healthy individuals.1
Similar pharmacokinetics in geriatric and younger patients.5
Solution for Injection
For information on systemic interactions resulting from concomitant use, see Interactions.
Should not be mixed with other injections or infusions unless specific compatibility data support such admixtures.1
Advice to Patients
Importance of advising patients who have had neuraxial anesthesia or spinal puncture to monitor for manifestations of spinal or epidural hematoma (e.g., tingling or numbness in lower limbs, muscle weakness), particularly if they are receiving concomitant NSAIAs, platelet-aggregation inhibitors, or other anticoagulants; importance of immediately contacting a clinician if any of these manifestations occur.1
If therapy is to continue following hospital discharge, importance of instructing patient and/or caregiver regarding dalteparin administration procedures.1
Importance of informing patients that they may bruise and/or bleed more easily and that a longer than normal time may be required to stop bleeding when taking enoxaparin.1 Importance of reporting any unexplained bleeding, bruising, or signs of thrombocytopenia (rash of dark red spots under skin) to clinician.1
Advise patient to inform dentists and physicians about dalteparin therapy before scheduling surgery or taking new drugs.1
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs (e.g., aspirin, other NSAIAs).1
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1
Importance of informing patients of other important precautionary information.1 (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Injection, for subcutaneous use only
2500 units/0.2 mL
Fragmin (available as single-dose prefilled syringes)
5000 units/0.2 mL
Fragmin (available as single-dose prefilled syringes)
7500 units/0.3 mL
Fragmin (available as single-dose prefilled syringes)
10,000 units/0.4 mL
Fragmin (available as single-dose prefilled syringes)
12,500 units/0.5 mL
Fragmin (available as single-dose prefilled syringes)
15,000 units/0.6 mL
Fragmin (available as single-dose prefilled syringes)
18,000 units/0.72 mL
Fragmin (available as single-dose prefilled syringes)
10,000 units/ mL
Fragmin (available as single-dose graduated syringes)
95,000 units/9.5 mL (10,000 units/mL)
Fragmin (available as multiple-dose vial)
Fragmin (available as multiple-dose vial)
95,000 units/3.8 mL (25,000 units/mL)
Fragmin (available as multiple-dose vial)
AHFS DI Essentials. © Copyright 2018, Selected Revisions October 23, 2017. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.
1. Pfizer. Fragmin (dalteparin sodium injection) prescribing information. New York, NY; 2014 Mar.
2. Pharmacia & Upjohn, Inc. Product information form for American hospital formulary service: Fragmin (dalteparin sodium injection). Columbus, OH; undated.
3. Hirsh J, Levine MN. Low molecular weight heparin. Blood. 1992; 79:1-17. http://www.ncbi.nlm.nih.gov/pubmed/1309422?dopt=AbstractPlus
4. Noble S, Peters DH, Goa KL. Enoxaparin: a reappraisal of its pharmacology and clinical applications in the prevention and treatment of thromboembolic disease. Drugs. 1995; 49:388-410. http://www.ncbi.nlm.nih.gov/pubmed/7774513?dopt=AbstractPlus
5. Simoneau G, Bergmann JF, Kher A et al. Pharmacokinetics of a low molecular weight heparin [Fragmin] in young and elderly subjects. Thromb Res. 1992; 66:603-7. http://www.ncbi.nlm.nih.gov/pubmed/1326135?dopt=AbstractPlus
6. Ockelford PA, Patterson J, Johns AS. A double-blind randomized placebo controlled trial of thromboprophylaxis in major elective general surgery using once daily injections of a low molecular weight heparin fragment (Fragmin). Thromb Haemost. 1989; 62:1046-9. http://www.ncbi.nlm.nih.gov/pubmed/2559484?dopt=AbstractPlus
7. Kakkar VV, Cohen AT, Edmonson RA et al et al. Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery. Lancet. 1993; 341:259-65. http://www.ncbi.nlm.nih.gov/pubmed/8093915?dopt=AbstractPlus
8. Caen JP. A randomized double-blind study between a low molecular weight heparin Kabi 2165 and standard heparin in the prevention of deep vein thrombosis in general surgery: a French multicenter trial. Thromb Haemost. 1988; 59:216-20. http://www.ncbi.nlm.nih.gov/pubmed/2838923?dopt=AbstractPlus
9. Hartl P, Brücke P, Dienstl E et al. Prophylaxis of thromboembolism in general surgery: comparison between standard heparin and Fragmin. Thromb Res. 1990; 57:577-84. http://www.ncbi.nlm.nih.gov/pubmed/2158151?dopt=AbstractPlus
10. Bergqvist D, Burmark US, Frisell J et al. Thromboprophylactic effect of low molecular weight heparin started in the evening before elective general abdominal surgery: a comparison with low-dose heparin. Semin Thromb Hemost. 1990; 16(Suppl):19-24. http://www.ncbi.nlm.nih.gov/pubmed/1962900?dopt=AbstractPlus
11. Phillips JK, Majumdar G, Hunt BJ et al. Heparin-induced skin reaction due to two different preparations of low molecular weight heparin (LMWH). Br J Haematol. 1993; 84:349-50. http://www.ncbi.nlm.nih.gov/pubmed/8398843?dopt=AbstractPlus
12. Manoharan A. Heparin-induced skin reaction with low molecular-weight heparin. Eur J Haematol. 1992; 48:234. http://www.ncbi.nlm.nih.gov/pubmed/1317299?dopt=AbstractPlus
13. Monreal M, Lafoz E, Salvador R et al. Adverse effects of three different forms of heparin therapy: thrombocytopenia, increased transaminases, and hyperkalaemia. Eur J Clin Pharmacol. 1989; 37:415-8. http://www.ncbi.nlm.nih.gov/pubmed/2557219?dopt=AbstractPlus
14. Bell WR, Royall RM. Heparin-associated thrombocytopenia: a comparison of three heparin preparations. N Engl J Med. 1980; 303:902-7. http://www.ncbi.nlm.nih.gov/pubmed/6997743?dopt=AbstractPlus
15. Sandoz Pharmaceuticals Corporation. Embolex (dihydroergotamine mesylate and heparin sodium; with lidocaine hydrochloride) injection prescribing information. East Hanover, NJ; 1987 Jun 26.
16. Abbott Laboratories. Intravenous solutions with heparin sodium injection prescribing information. North Chicago, IL; 1985 Jan.
17. Wyeth Laboratories. Heparin sodium injection prescribing information. Philadelphia, PA; 1989 Sep 22.
18. King DJ, Kelton JG. Heparin-associated thrombocytopenia. Ann Intern Med. 1984; 100:535-40. http://www.ncbi.nlm.nih.gov/pubmed/6367579?dopt=AbstractPlus
19. Bergqvist D, Burmark US, Frisell J et al. Low molecular weight heparin once daily compared with conventional low-dose heparin twice daily. A prospective double-blind multicentre trial on prevention of postoperative thrombosis. Br J Surg. 1986; 73:204-8. http://www.ncbi.nlm.nih.gov/pubmed/3512031?dopt=AbstractPlus
20. Bergqvist D, Mätzsch T, Burmark US et al. Low molecular weight heparin given the evening before surgery compared with conventional low-dose heparin in prevention of thrombosis. Br J Surg. 1988; 75:888-91. http://www.ncbi.nlm.nih.gov/pubmed/2846113?dopt=AbstractPlus
21. Fricker JP, Vergnes Y, Schach R et al. Low dose heparin versus low molecular weight heparin (Kabi 2165, Fragmin) in the prophylaxis of thromboembolic complications of abdominal oncological surgery. Eur J Clin Invest. 1988: 18:561-7.
22. Fleeger CA, ed. USAN 1995: USAN and the USP dictionary of drug names. Rockville, MD: The United States Pharmacopeial Convention, Inc; 1995:191.
23. Mattsson C, Palm M, Söderberg K et al. Antithrombotic effects of heparin oligosaccharides. Ann NY Acad Sci. 1989; 556:323-32. http://www.ncbi.nlm.nih.gov/pubmed/2735663?dopt=AbstractPlus
24. Andersson LO, Barrowcliffe TW, Holmer E et al. Molecular weight dependency of the heparin potentiated inhibition of thrombin and activated factor X. Effect of heparin neutralization in plasma. Thromb Res. 1979; 15:531-41. http://www.ncbi.nlm.nih.gov/pubmed/494159?dopt=AbstractPlus
25. Holmer E, Soderberg K, Bergqvist D et al. Heparin and its low molecular weight derivatives: anticoagulant and antithrombotic properties. Haemostasis. 1986; 16(Suppl 2):1-7. http://www.ncbi.nlm.nih.gov/pubmed/3744129?dopt=AbstractPlus
26. Neville GA, Racey TJ, Rochon P et al. Physicochemical characterization of the first World Health Organization international standard for low molecular weight heparin derivatives. J Pharm Sci. 1990; 79:425-7. http://www.ncbi.nlm.nih.gov/pubmed/2161923?dopt=AbstractPlus
27. Clagett GP, Anderson FA, Heit J et al. Prevention of venous thromboembolism. Chest. 1995; 108(Suppl):312-34S.
28. Becker RC, Ansell J. Antithrombotic therapy: an abbreviated reference for clinicians. Arch Intern Med. 1995; 155:149-61. http://www.ncbi.nlm.nih.gov/pubmed/7811124?dopt=AbstractPlus
29. Hirsh J, Dalen JE, Deykin D et al. Heparin: mechanism of action, pharmacokinetics, dosing considerations, monitoring, efficacy, and safety. Chest. 1992; 102(Suppl): 337-51S.
30. Pharmacia & Upjohn, Kalamazoo, MI: Personal communication.
31. Thomas DP, Barrowcliffe TW, Johnson EA. The influence of tissue source, salt and molecular weight on heparin activity. Scand J Haematol Suppl. 1980; 36:40-9. http://www.ncbi.nlm.nih.gov/pubmed/7006054?dopt=AbstractPlus
32. National Institutes of Health Office of Medical Applications of Research. Consensus conference: prevention of venous thrombosis and pulmonary embolism. JAMA. 1986; 256:744-9. http://www.ncbi.nlm.nih.gov/pubmed/3723773?dopt=AbstractPlus
33. Bergqvist D, Burmark US, Flordal PA et al. Low molecular weight heparin started before surgery as prophylaxis against deep vein thrombosis: 2500 versus 5000 XaI units in 2070 patients. Br J Surg. 1995; 82:496-501. http://www.ncbi.nlm.nih.gov/pubmed/7613894?dopt=AbstractPlus
34. Anon. Dalteparin—another low–molecular–weight heparin. Met Lett Drugs Ther. 1995; 37:115-6.
35. Lumpkin MM. Dear health care professional letter regarding reports of epidural or spinal hematomas with concurrent use of low molecular weight heparins or heparinoids and spinal/epidural anesthesia or spinal puncture. Rockville, MD: US Food and Drug Administration; 1997 Dec 15.
36. Richter C, Huch A, Huch R. Transfer of low molecular heparin during breast feeding. XVIth Congress of the International Society on Thrombosis and Haemostasis, Florence, Italy, 1997 Jun 6–12. Abstract No. PS-2998.
37. Forestier F, Sole Y, Aiach M et al. Absence of transplacental passage of Fragmin (Kabi) during the second and the third trimesters of pregnancy. Thromb Haemost. 1992; 67:180-1. http://www.ncbi.nlm.nih.gov/pubmed/1319615?dopt=AbstractPlus
38. Borg JY, Vasse M. Thrombosis prophylaxis in protein C or S deficient pregnant women: low molecular weight heparin management using prethrombotic markers as compared to normal pregnancies. Thromb Haemost. 1991; 65:1233.
39. Melissari E, Parker C, Wilson N et al. Use of low molecular weight heparin in pregnancy. Thromb Haemost. 1992; 68:652-6. http://www.ncbi.nlm.nih.gov/pubmed/1337628?dopt=AbstractPlus
40. Rasmussen C, Wadt J, Jacobsen B. Thromboembolic prophylaxis with low molecular weight heparin during pregnancy. Int J Gynaecol Obstet. 1994; 47:121-5. http://www.ncbi.nlm.nih.gov/pubmed/7843480?dopt=AbstractPlus
41. Hunt BJ, Doughty HA, Majumdar G et al. Thromboprophylaxis with low molecular weight heparin (Fragmin) in high risk pregnancies. Thromb Haemost. 1997; 77:39-43. http://www.ncbi.nlm.nih.gov/pubmed/9031446?dopt=AbstractPlus
42. Wahlberg TB, Kher A. Low molecular weight heparin as thromboprophylaxis in pregnancy. Haemostasis. 1994; 24:55-6. http://www.ncbi.nlm.nih.gov/pubmed/7959357?dopt=AbstractPlus
43. Hellgren M, Bremme K, Blomback M et al. Thromboprophylaxis with Fragmin during pregnancy. Blood Coagul Fibrinolysis. 1996; 7:401.
44. Blomback M, Hellgren M, Bremme K et al. Thromboprophylaxis with Fragmin during pregnancy. Haemostasis. 1996; 26(Suppl 3):418.
45. Shefras J, Farquharson RG. Bone density studies in pregnant women receiving heparin. Eur J Obstet Gynecol. 1996; 65:171-4.
46. Monreal M, Lafoz E, Olive A et al. Comparison of subcutaneous unfractionated heparin with a low molecular weight heparin (Fragmin) in patients with venous thrombembolism and contraindications to coumarin. Thromb Haemost. 1994; 71:7-11. http://www.ncbi.nlm.nih.gov/pubmed/8165649?dopt=AbstractPlus
47. Sivakumaran M, Ghoshi K, Zaidi Y et al. Osteoporosis and vertebral collapse following low-dose, low molecular weight heparin therapy in a young patient. Clin Lab Haematol. 1996; 18:55-7. http://www.ncbi.nlm.nih.gov/pubmed/9118608?dopt=AbstractPlus
48. Shiozaki A, Arai T, Izumi R et al. Congenital antithrombin III deficient neonate treated with antithrombin III concentrates. Thromb Res. 1993; 70:211-6. http://www.ncbi.nlm.nih.gov/pubmed/8327986?dopt=AbstractPlus
51. Fragmin and Fast Revascularization during Instability in Coronary Artery Disease (FRISC II) Investigators. Long-term low-molecular-mass heparin in unstable coronary-artery disease: FRISC II prospective randomized multicentre study. Lancet. 1999; 354:701-7. http://www.ncbi.nlm.nih.gov/pubmed/10475180?dopt=AbstractPlus
52. Fragmin during Instability in Coronary Artery Disease (FRISC) study group. Low-molecular-weight heparin during instability in coronary artery disease. Lancet. 1996; 347:561-8. http://www.ncbi.nlm.nih.gov/pubmed/8596317?dopt=AbstractPlus
53. Wallentin L, Lagerqvist B, Husted S et al. Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRISC II invasive randomised trial. Lancet. 2000; 356:9-16. http://www.ncbi.nlm.nih.gov/pubmed/10892758?dopt=AbstractPlus
54. Klein W, Buchwald A, Hillis SE et al. Comparison of low-molecular-weight heparin with unfractionated heparin acutely and with placebo for 6 weeks in the management of unstable coronary artery disease: Fragmin in Unstable Coronary Artery Disease Study (FRISC). Circulation. 1997; 96:61-8. http://www.ncbi.nlm.nih.gov/pubmed/9236418?dopt=AbstractPlus
55. Wallentin L. New trials of LMW heparins-light and heavy weight as good on short but what about longer distances? Eur Heart J. 1999; 20:1522-24.
56. Agency for Health Care Policy and Research. Diagnosing and managing unstable angina. 1994. (AHCPR publication no. 94-0603)
57. Cohen M, Demers C, Gurfinkel EP et al. A comparison of low-molecular-weigh heparin with unfractionated heparin for unstable coronary artery disease. N Engl J Med. 1997; 337:447-52. http://www.ncbi.nlm.nih.gov/pubmed/9250846?dopt=AbstractPlus
58. Antman EM, McCabe CH, Gurfinkel EP et al. Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) 11B trial. Circulation. 1999; 100:1593-601. http://www.ncbi.nlm.nih.gov/pubmed/10517729?dopt=AbstractPlus
59. Antman EM, Cohen M, Radley D et al. Asessment of the treatment effect of enoxapain for unstable angina/non-Q-wave myocardial infarction: TIMI 11B-ESSENCE meta-analysis. Circulation. 1999; 100:1602-8. http://www.ncbi.nlm.nih.gov/pubmed/10517730?dopt=AbstractPlus
60. Hull RD, Pineo GF, Francis C et al. Low-molecular-weight heparin prophylaxis using dalteparin in close proximity to surgery vs warfarin in hip arthoplasty patients: a double-blind, randomized comparison. Arch Intern Med. 2000; 160:2199-207. http://www.ncbi.nlm.nih.gov/pubmed/10904464?dopt=AbstractPlus
61. Armstrong PW. Pursuing progress in acute coronary syndromes. Circulation. 1999; 100:1586-9. http://www.ncbi.nlm.nih.gov/pubmed/10517727?dopt=AbstractPlus
63. Francis CW, Pelligrini VD, Totterman S et al. Prevention of deep-vein thrombosis after total hip arthroplasty: comparison of warfarin and dalteparin. J Bone Joint Surg Am. 1997; 79:1365-72. http://www.ncbi.nlm.nih.gov/pubmed/9314399?dopt=AbstractPlus
64. Eriksson BI, Kalebo P, Anthymyr BA et al. Prevention of deep-vein thrombosis and pulmonary embolism after total hip replacement. Comparions of low-molecular-weight heparin and unfractionated heparin. J Bone Joint Surg Am. 1991; 73:484-93. http://www.ncbi.nlm.nih.gov/pubmed/2013587?dopt=AbstractPlus
65. Howard PA. Dalteparin: a low-molecular-weight heparin. Ann Pharmacother. 1997; 31:192-203. http://www.ncbi.nlm.nih.gov/pubmed/9034422?dopt=AbstractPlus
66. Eikelboom JW, Anand SA, Malmberg K et al. Unfractionated heparin and low-molecular-weight heparin in acute coronary syndrome without ST elevation: a meta-analysis. Lancet. 2000; 355:1936-42. http://www.ncbi.nlm.nih.gov/pubmed/10859038?dopt=AbstractPlus
67. American Academy of Pediatrics Committee on Drugs. Policy statement. “Inactive” ingredients in pharmaceutical products: update (subject review). Elk Grove Village, IL: American Academy of Pediatrics; 1997.
68. Anon. Benzyl alcohol may be toxic to newborns. FDA Drug Bull. 1982; 12(2):10-11. http://www.ncbi.nlm.nih.gov/pubmed/7188569?dopt=AbstractPlus
69. Centers for Disease Control. Neonatal deaths associated with use of benzyl alcohol. MMWR Morb Mortal Wkly Rep. 1982; 31:290-1. http://www.ncbi.nlm.nih.gov/pubmed/6810084?dopt=AbstractPlus
70. Gershanik J, Boecler B, Ensley H et al. The gasping syndrome and benzyl alcohol poisoning. N Engl J Med. 1982; 307:1384-8. http://www.ncbi.nlm.nih.gov/pubmed/7133084?dopt=AbstractPlus
71. Menon PA, Thach BT, Smith CH et al. Benzyl alcohol toxicity in a neonatal intensive care unit: incidence, symptomatology, and mortality. Am J Perinatol. 1984; 1:288-92. http://www.ncbi.nlm.nih.gov/pubmed/6440575?dopt=AbstractPlus
72. Anderson CW, Ng KJ, Andresen B et al. Benzyl alcohol poisoning in a premature newborn infant. Am J Obstet Gynecol. 1984; 148:344-6. http://www.ncbi.nlm.nih.gov/pubmed/6695984?dopt=AbstractPlus
76. Kaul S, Shah PK. Low molecular weight heparin in acute coronary syndrome: evidence for superior or equivalent efficacy compared with unfractionated heparin? J AM Coll Cardiol. 2000; 35:1699-702.
77. Wysowski DK, Talarico L, Bacsanyi J et al. Spinal and epidural hematoma and low-molecular-weight heparin. N Engl J Med. 1998; 338:1774. http://www.ncbi.nlm.nih.gov/pubmed/9625640?dopt=AbstractPlus
78. Weitz JI. Low molecular weight heparins. N Engl J Med. 1998; 338:687-8. http://www.ncbi.nlm.nih.gov/pubmed/9490390?dopt=AbstractPlus
79. Horlocker TT, Heit JA. Low moleuclar weight heparin: biochemisty, pharmacology, perioperative prophylaxis regimens, and guidelines for reginal anesthetic management. Anesth Analg. 1997; 85: 874-85. http://www.ncbi.nlm.nih.gov/pubmed/9322474?dopt=AbstractPlus
80. Anon. Benzyl alcohol may be toxic to newborns. FDA Drug Bull. 1982; 12(2):10-11.
81. Centers for Disease Control. Neonatal deaths associated with use of benzyl alcohol. MMWR. 1982; 31:290-1.
82. Gershanik J, Boecler B, Ensley H et al. The gasping syndrome and benzyl alcohol poisoning. N Engl J Med. 1982; 307:1384-8.
83. Menon PA, Thach BT, Smith CH et al. Benzyl alcohol toxicity in a neonatal intensive care unit: incidence, symptomatology, and mortality. Am J Perinatol. 1984; 1:288-92.
84. Anderson CW, Ng KJ, Andresen B et al. Benzyl alcohol poisoning in a premature newborn infant. Am J Obstet Gynecol. 1984; 148:344-6.
86. Leyvraz PF, Bachmann F, Buller HR et al. Prevention of deep vein thrombosis after hip replacement: randomised comparison between unfractionated heparin and low molecular weight heparin. BMJ. 1991; 303:543-8 (IDIS 285212) http://www.ncbi.nlm.nih.gov/pubmed/1655136?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=1670889&blobtype=pdf
87. Dolovich LR, Ginsberg JS, Douketis JD et al. A meta-analysis comparing low-molecular-weight heparins with unfractionated heparin in the treatment of venous thromboembolism: examining some unanswered questions regarding location of treatment, product type, and dosing frequency. Arch Intern Med. 2000; 160:181-8. http://www.ncbi.nlm.nih.gov/pubmed/10647756?dopt=AbstractPlus
89. Gould MK, Dembitzer AD, Doyle RL et al. Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep vein thombosis: a meta-analysis of randomized, controlled trials. Ann Intern Med. 1999; 130:800-9. http://www.ncbi.nlm.nih.gov/pubmed/10366369?dopt=AbstractPlus
97. American Society of Health-System Pharmacists. ASHP therapeutic position statement on antithrombotic therapy in chronic atrial fibrillation. Am J Health Syst Pharm. 1998; 55: 376-81.
98. Fuster V, Ryden LE, Assinger RW et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114:257-354.
100. McNamara RL, Bass EB, Miller MR et al. Management of new onset atrial fibrillation. Evidence Report/Technology Assessment No. 12. Rockville, MD: Agency for Healthcare Research and Quality. 2001 Jan. (AHRQ publication No. 01-E026.)
101. Aventis. Lovenox (enoxaparin sodium) injection prescribing information. Bridgewater, NJ; 2003 Jul.
102. Pharmacia, Kalamazoo, MI: Personal communication.
103. Antman EM, Fox KM for the International Cardiology Forum. Guidelines for the diagnosis and management of unstable angina and non-Q-wave myocardial infarction: proposed revisions. Am Heart J; 2000;139:461-75.
104. Yeghiazarians Y, Braunstein JB, Askari A. Unstable angina pectoris. N Engl J Med. 2000; 342:101-14. http://www.ncbi.nlm.nih.gov/pubmed/10631280?dopt=AbstractPlus
107. Kramer A, Gurevitch J et al. Low-molecular weight heparin for prosthetic heart valves: treatment failure. Ann Thorac Surg. 2000; 69:264-6. http://www.ncbi.nlm.nih.gov/pubmed/10654529?dopt=AbstractPlus
108. Rowan JA,, McCowan LM, Raudkivi PJ et al. Enoxaparin treatment in women with mechanical heart valves during pregnancy. Am J Obstet Gynecol. 2001; 185:633-7. http://www.ncbi.nlm.nih.gov/pubmed/11568791?dopt=AbstractPlus
109. Oles D,, Berryessa R, Campbell K et al. Emergency redo mitral valve replacement in a 27-year-old pregnant female with a clotted prosthetic mitral valve, preoperative fetal demise and postoperative ventricular assist device: a case report. Perfusion. 2001; 16:159-64. http://www.ncbi.nlm.nih.gov/pubmed/11334200?dopt=AbstractPlus
110. American College of Obstetricians and Gynecologists. ACOG Committee Opinion: safety of lovenox in pregnancy. Obstet Gynecol. 2002;100:845-6.
111. Ginsberg JS, Chan WS, Bates SM et al. Anticoagulation of pregnant women with mechanical heart valves. Arch Intern Med. 2003; 163:694-8. http://www.ncbi.nlm.nih.gov/pubmed/12639202?dopt=AbstractPlus
112. Leyh RT, Fischer S, Ruhparwar A et al. Anticoagulant therapy in pregnant women with mechanical heart valves. Arch Gynecol Obstet. 2003; 268:1-4 http://www.ncbi.nlm.nih.gov/pubmed/12673466?dopt=AbstractPlus
113. Mahesh B, Evans S, Bryan AJ. Failure of low molecular-weight heparin in the prevention of prosthetic mitral valve thrombosis during pregnancy: case report and a review of options for anticoagulation. J Heart Valve Dis. 2002; 11:745-50 http://www.ncbi.nlm.nih.gov/pubmed/12358414?dopt=AbstractPlus
114. Berndt N, Khan I, Gallo R. A complication in anticoagulation using low-molecular weight heparin in a patient with a mechanical valve prosthesis. A case report. J Heart Valve Dis. 2000; 9:844-6 http://www.ncbi.nlm.nih.gov/pubmed/11128796?dopt=AbstractPlus
115. Aventis Pharmaceuticals. Personal communication on enoxaparin monograph
125. Leizorovicz A, Cohen AT, Turpie AGG et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004; 110:874-9. http://www.ncbi.nlm.nih.gov/pubmed/15289368?dopt=AbstractPlus
126. Wells PS, Anderson DR, Rodger MA et al. A randomized trial comparing 2 low-molecular-weight heparins for the outpatient treatment of deep-vein thrombosis and pulmonary embolism. Arch Intern Med. 2005; 165:733-738. http://www.ncbi.nlm.nih.gov/pubmed/15824291?dopt=AbstractPlus
127. Eikelboom JW, Hankey GJ. Low molecular weight heparins and heparinoids. Med J Aust. 2002; 177:379-83. http://www.ncbi.nlm.nih.gov/pubmed/12358583?dopt=AbstractPlus
128. Vitale N, De Feo M, De Santo LS et al. Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves. J Am Coll Cardiol. 1999; 33:1637-41. http://www.ncbi.nlm.nih.gov/pubmed/10334435?dopt=AbstractPlus
129. Leyh RG, Fischer S, Ruhparwar A et al. Anticoagulation for prosthetic heart valves during pregnancy: is low-molecular-weight heparin an alternative? Eur J Cardiothorac Surg. 2002; 21:577-9.
130. Vitale N, De Feo M, Cotrufo M. Anticoagulation for prosthetic heart valves during pregnancy: the importance of warfarin daily dose. Eur J Cardiothorac Surg. 2002; 22:656-7. http://www.ncbi.nlm.nih.gov/pubmed/12297198?dopt=AbstractPlus
131. Aventis. Lovenox (enoxaparin sodium) injection prescribing information. Bridgewater, NJ; 2004 Jul.
132. Chan WS, Anand S, Ginsberg JS. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. Arch Intern Med. 2000; 160:191-6. http://www.ncbi.nlm.nih.gov/pubmed/10647757?dopt=AbstractPlus
133. Elkayam UR. Anticoagulation in pregnant women with prosthetic heart valves: a double jeopardy. J Am Coll Cardiol. 1996; 27:1704-6. http://www.ncbi.nlm.nih.gov/pubmed/8636557?dopt=AbstractPlus
134. Salazar E, Izaguirre R, Verdejo J et al. Failure of adjusted doses of subcutaneous heparin to prevent thromboembolic phenomena in pregnant patients with mechanical cardiac valve prostheses. J Am Coll Cardiol. 1996; 27:1698-703. http://www.ncbi.nlm.nih.gov/pubmed/8636556?dopt=AbstractPlus
135. Adams H, Adams R, Del Zoppo G et al. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update. A scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke. 2005; 36:916-21. http://www.ncbi.nlm.nih.gov/pubmed/15800252?dopt=AbstractPlus
136. Adams H, Adams R, Brott T et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke. 2003; 34:1056-83. http://www.ncbi.nlm.nih.gov/pubmed/12677087?dopt=AbstractPlus
137. Levine M, Gent M, Hirsch J et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med. 1996; 334:677-81. http://www.ncbi.nlm.nih.gov/pubmed/8594425?dopt=AbstractPlus
138. Elkayam U. Pregnancy through a prosthetic heart valve. J Am Coll Cardiol. 1999; 33:1642-5. http://www.ncbi.nlm.nih.gov/pubmed/10334436?dopt=AbstractPlus
139. Meschengieser SS, Fondevila CG, Santarelli MT et al. Anticoagulation in pregnant women with mechanical heart valve prostheses. Heart. 1999; 82:23-6 http://www.ncbi.nlm.nih.gov/pubmed/10377303?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=1729094&blobtype=pdf
140. Bhatt DL, Roe MT, Peterson ED et al. Utilization of early invasive management strategies for high-risk patients with non–ST-segment elevation acute coronary syndromes. Results from the CRUSADE Quality Improvement Initiative. JAMA. 2004; 292:2096-2104. http://www.ncbi.nlm.nih.gov/pubmed/15523070?dopt=AbstractPlus
141. Gluckman TJ, Sachdev M, Schulman SP et al. A simplified approach to the management of non–ST-segment elevation acute coronary syndromes. JAMA. 2005; 293:349-357. http://www.ncbi.nlm.nih.gov/pubmed/15657328?dopt=AbstractPlus
142. Cannon CP, Weintraub WS, Demopoulos LA et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001; 344:1879–87. http://www.ncbi.nlm.nih.gov/pubmed/11419424?dopt=AbstractPlus
143. Braunwald E. Application of current guidelines to the management of unstable angina and non-ST-elevation myocardial infarction. Circulation. 2003; 108[Suppl III]:III-28-37.
147. Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 Investigators. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction. Lancet. 2001; 358:605-13. http://www.ncbi.nlm.nih.gov/pubmed/11530146?dopt=AbstractPlus
148. Wallentin L, Goldstein P, Armstrong PW et al. Efficacy and safety of tenecteplase in combination with the low-molecular-weight heparin enoxaparin or unfractionated heparin in the prehospital setting: the Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 PLUS randomized trial in acute myocardial infarction. Circulation. 2003; 108:135-42. http://www.ncbi.nlm.nih.gov/pubmed/12847070?dopt=AbstractPlus
149. Ross AM, Molhoek P, Lundergan C et al, for the HART II Investigators. Randomized comparison of enoxaparin, a low molecular weight heparin, with unfractionated heparin adjunctive to recombinant tissue plasminogen activator thrombolysis and aspirin: second trial of Heparin and Aspirin Reperfusion Therapy (HART II). Circulation. 2001; 104:648-52. http://www.ncbi.nlm.nih.gov/pubmed/11489769?dopt=AbstractPlus
150. Wallentin L, Bergstrand L, Dellborg M et al. Low molecular weight heparin (dalteparin) compared to unfractionated heparin as an adjunct to rt-PA (alteplase) for improvement of coronary artery patency in acute myocardial infarction-the ASSENT Plus study. Eur Heart J. 2003; 24:897-908. http://www.ncbi.nlm.nih.gov/pubmed/12714021?dopt=AbstractPlus
151. Baird SH, Menown IB, Mcbride SJ et al. Randomized comparison of enoxaparin with unfractionated heparin following fibrinolytic therapy for acute myocardial infarction. Eur Heart J. 2002; 23:627-32. http://www.ncbi.nlm.nih.gov/pubmed/11969277?dopt=AbstractPlus
152. Lansky AJ, Hochman JS, Ward PA et al. Percutaneous coronary intervention and adjunctive pharmacotherapy in women: a statement for healthcare professional from the American Heart Association. Circulation. 2005; 111:940-3. http://www.ncbi.nlm.nih.gov/pubmed/15687113?dopt=AbstractPlus
154. Sacco RL, Adams R, Albers G et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke. Stroke. 2006; 37:577-617. http://www.ncbi.nlm.nih.gov/pubmed/16432246?dopt=AbstractPlus
158. Lee AYY, Levine MN, Baker RI et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 2003; 349:146-53. http://www.ncbi.nlm.nih.gov/pubmed/12853587?dopt=AbstractPlus
161. US Food and Drug Administration. FDA drug safety communications: Updated recommendations to decrease risk of spinal column bleeding and paralysis in patients on low molecular weight heparins. 2013 Nov 6. From the FDA website. http://www.fda.gov/Drugs/DrugSafety/ucm373595.htm
163. Horlocker TT, Wedel DJ, Rowlingson JC et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010 Jan-Feb; 35:64-101.
991. Anderson JL, Adams CD, Antman EM et al. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011; 123:e426-579.
994. Levine GN, Bates ER, Blankenship JC et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011; 58:e44-122. http://www.ncbi.nlm.nih.gov/pubmed/22070834?dopt=AbstractPlus
996. Bonow RO, Carabello BA, Chatterjee K et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008; 118:e523-661.
999. Fuster V, Rydén LE, Cannom DS et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2011; 123:e269-367.
1000. Holbrook A, Schulman S, Witt DM et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e152S-84S. http://www.ncbi.nlm.nih.gov/pubmed/22315259?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3278055&blobtype=pdf
1001. Kahn SR, Lim W, Dunn AS et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e195S-226S.
1002. Gould MK, Garcia DA, Wren SM et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e227S-77S. http://www.ncbi.nlm.nih.gov/pubmed/22315263?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3278061&blobtype=pdf
1003. Falck-Ytter Y, Francis CW, Johanson NA et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e278S-325S. http://www.ncbi.nlm.nih.gov/pubmed/22315265?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3278063&blobtype=pdf
1004. Douketis JD, Spyropoulos AC, Spencer FA et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e326S-50S.
1005. Kearon C, Akl EA, Comerota AJ et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e419S-94S. http://www.ncbi.nlm.nih.gov/pubmed/22315268?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3278049&blobtype=pdf
1006. Linkins LA, Dans AL, Moores LK et al. Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e495S-530S. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3278058&blobtype=pdf
1007. You JJ, Singer DE, Howard PA et al. Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e531S-75S. http://www.ncbi.nlm.nih.gov/pubmed/22315271?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3278056&blobtype=pdf
1008. Whitlock RP, Sun JC, Fremes SE et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e576S-600S. http://www.ncbi.nlm.nih.gov/pubmed/22315272?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3278057&blobtype=pdf
1009. Lansberg MG, O'Donnell MJ, Khatri P et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e601S-36S. http://www.ncbi.nlm.nih.gov/pubmed/22315273?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3278065&blobtype=pdf
1012. Bates SM, Greer IA, Middeldorp S et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e691S-736S. http://www.ncbi.nlm.nih.gov/pubmed/22315276?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3278054&blobtype=pdf
1013. Monagle P, Chan AK, Goldenberg NA et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e737S-801S. http://www.ncbi.nlm.nih.gov/pubmed/22315277?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3278066&blobtype=pdf
1017. Bushnell C, McCullough LD, Awad IA et al; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Council for High Blood Pressure Research. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014; 45:1545-88. http://www.ncbi.nlm.nih.gov/pubmed/24503673?dopt=AbstractPlus
1100. Amsterdam EA, Wenger NK, Brindis RG et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 130:e344-426. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=4676081&blobtype=pdf
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