Unfractionated Heparin |
Unfractionated heparin | 80 units/kg intravenous bolus, then continuous intravenous infusion of 18 units/kg/h | × | × | × | × | | Bolus may be omitted if risk of bleeding is perceived to be elevated. Maximum bolus, 10,000 units. Requires aPTT or heparin anti-Xa monitoring. Most patients: begin warfarin at time of initiation of heparin. |
| 330 units/kg subcutaneously × 1, then 250 units/kg subcutaneously every 12 hours | × | | | | | Fixed-dose; no aPTT monitoring required |
LMWH and Fondaparinux |
Enoxaparin3 | 1 mg/kg subcutaneously every 12 hours or 1.5 mg/kg subcutaneously daily | × | × | × | | | Most patients: begin warfarin at time of initiation of LMWH |
Dalteparin3 | 200 units/kg subcutaneously once daily for first month, then 150 units/kg/day | × | × | × | | × | Preferred LMWH for cancer patients; administer for at least 3–6 months (no transition to warfarin) |
Fondaparinux | 5–10 mg subcutaneously once daily; use 7.5 mg for body weight 50–100 kg; 10 mg for body weight > 100 kg | × | × | × | | | |
Direct-Acting Oral Anticoagulants (DOACs) |
Rivaroxaban | 15 mg orally twice daily with food for 21 days, then 20 mg orally daily with food | × | × | × | | × | Contraindicated if CrCl < 30 mL/min Monotherapy without need for initial parenteral therapy Caution in luminal gastrointestinal or genitourinary cancer |
Apixaban | 10 mg orally twice daily for first 7 days, then 5 mg twice daily | × | × | × | | × | Contraindicated if CrCl < 25 mL/min Monotherapy without need for initial parenteral therapy |
Dabigatran | 5–10 days of parenteral anticoagulation, then begin 150 mg orally twice daily | × | × | × | | | Contraindicated if CrCl < 15 mL/min Initial need for parenteral therapy |
Edoxaban | 5–10 days of parenteral anticoagulation, then 60 mg orally once daily; 30 mg once daily recommended if CrCl is between 15 and 50 mL/min, if weight ≤ 60 kg, or if certain P-gp inhibitors are present | × | × | × | | × | Contraindicated if CrCl < 15 mL/min Initial need for parenteral therapy Caution in luminal gastrointestinal or genitourinary cancer |