title: Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism.
abstract: Venous thromboembolism (VTE) is a serious and often fatal medical condition with an increasing incidence. Despite the changing landscape of VTE treatment with the introduction of the new direct oral anticoagulants many uncertainties remain regarding the optimal use of traditional parenteral agents. This manuscript, initiated by the Anticoagulation Forum, provides clinical guidance based on existing guidelines and consensus expert opinion where guidelines are lacking. This specific chapter addresses the practical management of heparins including low molecular weight heparins and fondaparinux. For each anticoagulant a list of the most common practice related questions were created. Each question was addressed using a brief focused literature review followed by a multidisciplinary consensus guidance recommendation. Issues addressed included initial anticoagulant dosing recommendations, recommended baseline laboratory monitoring, managing dose adjustments, evidence to support a relationship between laboratory tests and meaningful clinical outcomes, special patient populations including extremes of weight and renal impairment, duration of necessary parenteral therapy during the transition to oral therapy, candidates for outpatient treatment where appropriate and management of over-anticoagulation and adverse effects including bleeding and heparin induced thrombocytopenia. This article concludes with a concise table of clinical management questions and guidance recommendations to provide a quick reference for the practical management of heparin, low molecular weight heparin and fondaparinux.
authors.affiliation: Wayne State University, Detroit, MI, USA.
authors.forename: Maureen A
authors.initials: MA
authors.lastname: Smythe
authors.affiliation: Beaumont Health System, Troy, MI, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Priziola
authors.affiliation: University of Nebraska Medical Center College of Pharmacy, Omaha, NE, USA.
authors.forename: Paul P
authors.initials: PP
authors.lastname: Dobesh
authors.affiliation: Grady Memorial Hospital, Atlanta, GA, USA.
authors.forename: Diane
authors.initials: D
authors.lastname: Wirth
authors.affiliation: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Adam
authors.initials: A
authors.lastname: Cuker
authors.affiliation: University of Washington School of Pharmacy, 1959 NE Pacific St Box 356015, Seattle, WA, 98195, USA. akwitt@uw.edu.
authors.forename: Ann K
authors.initials: AK
authors.lastname: Wittkowsky
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D006493:Heparin / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D017410:Practice Guidelines as Topic; D054556:Venous Thromboembolism / Q000188:drug therapy*
chemical_list: D000925:Anticoagulants; D006493:Heparin
keywords: Anticoagulation; Dalteparin; Direct oral anticoagulants (DOAC); Enoxaparin; Fondaparinux; Heparin; Low molecular weight heparin; New oral anticoagulants (NOAC); Venous thromboembolism