dalteparin


dalteparin

 [dal-tep´ah-rin] an agent used as the sodium salt for prevention of pulmonary thromboembolism and deep venous thrombosis in at-risk abdominal surgery patients.

dalteparin

(dal-te-pa-rin) dalteparin,

Fragmin

(trade name)

Classification

Therapeutic: anticoagulants
Pharmacologic: antithrombotics
Pregnancy Category: B

Indications

Prevention of venous thromboembolism (deep vein thrombosis (DVT) and/or pulmonary embolism (PE)) in surgical or medical patients.Extended treatment of symptomatic DVT and/or PE in patients with cancer.Prevention of ischemic complications (with aspirin) in patients with:
  • unstable angina,
  • non–Q-wave MI.

Action

Potentiates the inhibitory effect of antithrombin on Factor Xa and thrombin.

Therapeutic effects

Prevention of thrombus formation.Decreased incidence of death or recurrent MI.

Pharmacokinetics

Absorption: Well absorbed (87%) after administration.Distribution: Unknown.Metabolism and Excretion: Unknown.Half-life: 2.1–2.3 hr.

Time/action profile (antithrombotic effect)

ROUTEONSETPEAKDURATION
Subcutrapid4 hrup to 24 hr

Contraindications/Precautions

Contraindicated in: Hypersensitivity to dalteparin, heparin, or pork products; Active major bleeding; Thrombocytopenia related to previous dalteparin therapy.Use Cautiously in: Patients with severe renal or hepatic impairment; Retinopathy (hypertensive or diabetic); Spinal or epidural anesthesia; Geriatric: Risk of bleeding may be ↑, consider age-related ↓ in renal function and body weight; Obstetric / Lactation / Pediatric: Safety not established; products containing benzyl alcohol should not be used in neonates.Exercise Extreme Caution in: Spinal/epidural anesthesia or spinal puncture (↑ risk of spinal/epidural hematoma that may lead to long-term or permanent paralysis); Severe uncontrolled hypertension; Bacterial endocarditis, bleeding disorders; GI bleeding/ulceration/pathology; Hemorrhagic stroke; Recent CNS or ophthalmologic surgery; Active GI bleeding/ulceration; History of thrombocytopenia related to heparin.

Adverse Reactions/Side Effects

Central nervous system

  • dizziness

Gastrointestinal

  • reversible ↑ in liver enzymes

Hematologic

  • bleeding
  • thrombocytopenia

Interactions

Drug-Drug interaction

Risk of bleeding ↑ by concurrent use of thrombolytics, anticoagulants, or agents that affect platelet function including NSAIDS, ticlopidine, clopidogrel, tirofiban, or eptifibatide.

Route/Dosage

DVT Prophylaxis

Subcutaneous (Adults) Abdominal surgery—2500 IU 1–2 hr before surgery, then once daily for 5–10 days; High-risk patients undergoing abdominal surgery—5000 IU evening before surgery, then once daily for 5–10 days or 2500 IU 1–2 hr before surgery, another 2500 IU 12 hour later, then 5000 IU daily for 5–10 days; Hip replacement surgery—2500 IU within 2 hr before surgery, another 2500 IU evening of the day of surgery ≥6 hr after first dose, then 5000 IU daily for 5–10 days (if surgery is in the evening omit second dose day of surgery) or 5000 IU evening before surgery, then 5000 IU daily for 5–10 days.Medical patients with severely restricted mobility: 5000 IU for 12 to 14 days.

Extended Treatment of Symptomatic VTE in Patients with Cancer

Subcutaneous (Adults) 200 IU/kg once daily (not to exceed 18,000 IU/day) for first 30 days, then 150 IU/kg once daily (not to exceed 18,000 IU/day) for months 2–6.

Angina/Non–Q-wave MI

Subcutaneous (Adults) 120 IU/kg (not to exceed 10,000 IU) q 12 hr with concurrent aspirin.

Renal Impairment

Subcutaneous (Adults) Cancer patients receiving extended treatment of symptomatic VTE with CCr <30 mL/min—Monitor anti-Xa levels (target 0.5–1.5 IU/mL).

Availability

Solution for injection (prefilled syringes): 2500 IU/0.2 mL, 5000 IU/0.2 mL, 7500 IU/0.3 mL, 10,000 IU/mL, 12,500 IU/0.5 mL, 15,000 IU/0.6 mL, 18,000 IU/0.72 mL Solution for injection (multidose vials): 25,000 IU/mL in 3.8–mL vials

Nursing implications

Nursing assessment

  • Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry stool; hematuria; fall in hematocrit or BP; guaiac-positive stools). Notify health care professional if these occur.
  • Subcutaneous: Observe injection sites for hematoma, ecchymosis, or inflammation.
  • Lab Test Considerations: Monitor CBC, platelet count, and stools for occult blood periodically during therapy. If thrombocytopenia occurs, monitor closely. If hematocrit ↓ unexpectedly, assess patient for potential bleeding sites.
    • Special monitoring of clotting times (aPTT) is not necessary.
    • May cause asymptomatic ↑ in transaminase levels (AST, ALT).

Potential Nursing Diagnoses

Ineffective tissue perfusion (Indications)
Risk for injury (Side Effects)

Implementation

  • First dose is administered 1–2 hr before surgery.
    • Dalteparin cannot be used interchangeably (unit for unit) with unfractionated heparin or other low-molecular-weight heparins.
  • Subcutaneous: Administer deep subcut while patient is sitting or lying down. Dalteparin may be injected into the abdominal wall inferior and lateral to the umbilicus, the upper outer side of the thigh, or the upper outer quadrant of the buttock. Rotate injection sites daily. Inject entire length of needle at a 45° or 90° angle while lifting and holding skin between thumb and forefinger.
    • Do not administer IM.
  • Syringe Incompatibility: Do not mix with other injections or infusions.

Patient/Family Teaching

  • Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to health care professional immediately.
  • Instruct patient not to take aspirin or NSAIDs without consulting health care professional while on dalteparin therapy.

Evaluation/Desired Outcomes

  • Prevention of deep vein thrombosis and pulmonary embolism.
  • Prevention of ischemic complications (with aspirin) in patients with unstable angina or non-Q-wave MI.
  • Reduction of recurrence of VTE in patients with cancer.