Clinical beta

FMBM is currently in clinical beta. Content is for professional review/testing and must not replace local protocols, senior clinical judgment, or official prescribing references.

Drug Monograph

Heparin

Heparin sodium (unfractionated)

Unfractionated heparin (UFH) β€” parenteral anticoagulant

IVVTEACSAdultHigh Yield

Indication

DVT/PE treatment β€’ ACS β€’ DIC (context) β€’ intra-op anticoagulation β€’ bridge

At a glance

INDICATIONS (CORE USE)

Continuous IV for acute VTE, ACS, bridging, procedures needing rapid offset; titrate **aPTT or anti-Xa**; **protamine** reverses.

ADULT DOSE (STANDARD)

IV bolus + infusion per weight-based protocol (e.g. 80 U/kg bolus + 18 U/kg/h) β€” **institutional nomogram**

MAX DOSE

No absolute ceiling in ICU β€” titrated to lab; watch bleeding

Route

IV continuous infusion (SC UFH rare)

PEDIATRIC DOSE

Neonatal/pediatric infusion protocols β€” weight-based β€” PICU/pharmacy

Do not miss

Must-not-miss safety points

Major warning

- **HIT** β€” any falling platelets or thrombosis on UFH β†’ stop and alternative anticoagulant - Bleeding with supratherapeutic aPTT β€” hold infusion + protamine if severe - Hyperkalemia, osteoporosis with prolonged use

Indications

USE IF: Need rapid titration, severe renal failure (vs LMWH accumulation), procedures, ACS, massive PE with thrombolysis context. AVOID IF: HIT, uncontrollable bleeding.

Primary

  • Acute VTE
  • ACS with anticoagulation pathway
  • Bridging when rapid on/off needed

Secondary

  • Intraoperative anticoagulation (e.g. cardiac bypass β€” specialized)
  • DIC treatment (controversial β€” specialist)

Other

  • Line patency flushes at low dose β€” distinct from therapeutic anticoagulation

Dosing

STANDARD (ADULT PO)

Weight-based infusion with q6h aPTT or anti-Xa adjustment per nomogram

ADULT DOSE

Bolus + drip per hospital protocol. Target **aPTT** or **anti-Xa** per lab standard. Transition to oral: overlap with warfarin until INR therapeutic or switch per DOAC table.

PEDIATRIC DOSE

PICU nomogram.

MAX DOSE

Lab-guided β€” not mg fixed.

Practical Note

Same patient on different UFH brands β€” potency units consistent if USP units.

Warnings

Clinical warnings

  • **HIT (all heparin):** β€’ **STOP ALL HEPARIN** (including **flushes**) β€’ **DO NOT switch to LMWH** β€’ **Start non-heparin anticoagulant** (per institutional HIT pathway + hematology) β€” **suspected / probable HIT**
  • HIT
  • Spinal hematoma with lumbar puncture timing

Adverse effects

  • Bleeding
  • HIT
  • osteoporosis long-term
  • hyperkalemia
  • elevated LFTs

Contraindications

  • **Suspected acute HIT** β€” **no UFH or LMWH** until non-heparin pathway per institutional protocol
  • **Active pathological / major bleeding** β€” stabilize/reverse per protocol before routine (re)start unless embedded in explicit reversal plan
  • **Upcoming invasive procedure** β€” **do not continue blindly**; document **hold/bridge/switch** with anesthesia/surgery when applicable
  • Active uncontrollable bleeding
  • Acute HIT
  • Severe thrombocytopenia without cause identified

Drug interactions

  • **NSAID, antiplatelet, or SSRI added** β†’ **bleeding risk ↑** β†’ **reassess stack** and procedure timing
  • **Renal decline** on renally cleared agent β†’ **dose/hold** per CrCl + pharmacy
  • Nitroglycerin may reduce UFH effect IV
  • antiplatelets
  • thrombolytics

Special populations

Pediatrics

Neonatal/pediatric infusion protocols β€” weight-based β€” PICU/pharmacy

Pregnancy

**Pregnancy:** does not cross placenta β€” used when needed; **

Lactation

** OK.

Renal impairment

Preferred agent when CrCl very low vs LMWH accumulation. **CrCl scaffold (FMBM β€” titrate to FDA/SFDA label + pharmacy / anticoagulation clinic):** - **CrCl β‰₯50** β†’ titrate by aPTT / anti-Xa β€” not mg-by-CrCl table - **CrCl 10–50** β†’ monitor closely; accumulation less than LMWH but bleeding risk illness-dependent - **CrCl <10** β†’ prefer monitored infusion + serial labs; **dialysis** does not remove UFH β€” protamine if needed

Hepatic impairment

Less hepatic clearance than LMWH metabolism nuances β€” still monitor bleed.

Elderly

May need lower infusion rates β€” fragility.

Administration

Dedicated IV line; smart pump; double-check units (U/mL).

Monitoring

  • Monitor: - β€’ **aPTT / anti-Xa** β†’ **q6h** until stable - β€’ **Platelets** β†’ monitor for **HIT** - β€’ **HIT** β†’ **STOP ALL HEPARIN** (including **flushes**) β†’ **DO NOT switch to LMWH** β†’ **non-heparin anticoagulant** - β€’ **Supratherapeutic, no bleed** β†’ reduce/hold infusion β†’ **aPTT / anti-Xa** **4–6h** - β€’ **Major bleed** β†’ **give protamine** (based on **recent heparin dose**; **delayed** = **partial reversal**) - β€’ **Neuraxial** β†’ **last bolus / infusion stop** vs catheter - aPTT or anti-Xa on schedule until stable - Daily CBC for HIT surveillance
  • Recheck: - **Interacting drug added or stopped** β†’ **recheck INR (warfarin) or reassess bleed risk / renal (DOAC)** within **48–72h** - If targets not met after reassessment of dose, organ function, and interactions β†’ escalate per protocol (DO NOT continue blindly)
  • Hold if:
    - **Bleeding, unexplained Hb drop, thunderclap headache, or focal neuro signs** β†’ **hold** anticoagulant + escalate per bleed protocol

Overdose / toxicity

Clinical Picture

β€’ **No bleed, high aPTT:** Titrate/hold infusion β†’ **recheck aPTT / anti-Xa** **4–6h** per nomogram β€’ **Minor bleed:** Brief hold β†’ restart lower β€’ **Major bleed:** **Stop UFH** (**+ flushes**) β†’ **give protamine** (based on **recent heparin dose**; **delayed** = **partial reversal**) β†’ **ICU**

Immediate Actions

β€’ **Stop UFH** (including **flushes**) β€’ **Major bleed** β†’ **protamine** β€’ **Check aPTT / anti-Xa** after intervention β€’ **Minor** β†’ hold / adjust **infusion**

Antidote

β€’ **Major bleed** β†’ **give protamine** (based on **recent heparin dose**; **delayed** = **partial reversal**)

Decontamination

β€’ **IV therapeutic:** N/A

Escalation

β€’ **Major:** **ICU**; **PCC** only desperate refractory bleed per protocol; spine imaging if indicated

Clinical pearls

Common mistakes, resistance logic, and bedside traps

High-Yield Summary

**Nomogram-driven** β€” never set-and-forget. β†’ **Protamine** works for UFH. β†’ **HIT** can be dramatic β€” watch platelets.

Clinical pearls

Renal failure often favors UFH over LMWH for reversible infusion control. **Heparin β€” detail (factory)** β€’ **HIT:** **DO NOT** substitute **UFH ↔ LMWH** β€” follow institution pathway + hematology β€’ **UFH neuraxial:** **Last bolus / infusion stop** vs catheter (**ASRA**) β€’ **LMWH neuraxial:** Therapeutic often **β‰₯24h** vs prophylaxis **β‰₯12h** (typical) β€” **ASRA** β€’ **LMWH:** CrCl **<30** therapeutic β†’ **↓ dose / daily / monitored UFH** if **not** HIT; **anti-Xa** only in **selected** cases (pregnancy, obesity/extreme weight, renal impairment, unusual bleed/thrombosis) per pharmacy β€” **not** routine titration β€’ **Protamine refractory bleed:** **PCC** per hematology pathway *Anticoagulation (all agents):* **A/B/C bleed tiers** β€” no bleed (hold/adjust) vs minor (hold/protocol) vs major (reversal + ICU/heme). **Warfarin:** high INR without bleed **β‰ ** major-bleed pathway; **PCC + IV K** for life-threatening bleed. **Bridging:** warfarin **slow on/off**; **parenteral overlap** when indicated for acute VTE; **no routine bridge** low-risk AF; **DOAC↔warfarin** table-specific. **Neuraxial:** explicit **last-dose β†’ procedure** documentation. Never extend therapy without indication review.

Anticoagulant safety

  • Lab titration
  • HIT platelets
  • Protamine available

Pharmacokinetics

IV immediate; short TΒ½; cleared reticuloendothelial + renal at higher doses.

Mechanism of action

Binds antithrombin β†’ inactivates thrombin and factor Xa (and others).

Common brand names

Saudi Arabia

Heparin, Liquemin

Global

Generic UFH, (placeholder β€” verify local prefilled syringe / vial)

Common trade names are curated examples only β€” formulations and availability vary. Verify the exact product name with your local pharmacy and national regulator before prescribing or dispensing.

Country practice notes

  • Reversal agents (PCC, andexanet, idarucizumab) availability and dosing vary by hospital β€” follow local protocol.
  • Perioperative interruption and bridging are **indication-specific** β€” do not copy warfarin rules onto DOACs blindly.
  • Switching between anticoagulants requires manufacturer tables + pharmacy to avoid under- or over-anticoagulation.

References

Saudi Arabia

  • SFDA (Saudi Food & Drug Authority)
  • Saudi National Formulary / MOH (where available)

International

  • WHO Model List of Essential Medicines (verify current edition)
  • US FDA or EU EMA product information (when national SmPC is unavailable)
  • CHEST / ACCP antithrombotic guidance (indication-specific)
  • ESC / AHA stroke and anticoagulation guidelines where applicable
  • ASH β€” HIT and VTE resources
  • FDA / SFDA product labeling
  • Institutional anticoagulation service / formulary
  • CHEST / ACCP antithrombotic guidance (indication-specific)
  • ESC / AHA stroke and anticoagulation guidelines where applicable
  • ASH β€” HIT and VTE resources
  • FDA / SFDA product labeling
  • Institutional anticoagulation service / formulary

Do not miss

  • Document indication, target intensity, and planned duration in the chart
  • Reassess renal/hepatic function after AKI, dehydration, or new interacting medications
  • **HIT** β†’ stop **all heparin** (including **flushes**) β†’ start **non-heparin anticoagulant**
  • **Major bleed** β†’ **protamine** (dose/time dependent)
  • **aPTT above target** β†’ reduce/hold **infusion**
  • aPTT **>120s** with bleed β†’ stop drip + protamine.
  • Platelet **50% drop** β†’ HIT workup.
  • Lab titration
  • HIT platelets
  • Protamine available