Anticoagulants and Protamine

NHSL Medicines Guidance
NHS Lanarkshire

General Notes

For dosing recommendations, please refer to the BNF or individual product SPCs (available in the EMC).

PROTAMINE SULFATE reverses the effects of standard heparin, but only partially reverses the effects of low molecular weight heparins.

Parenteral Anticoagulants

Specialist initiation (S1)

FONDAPARINUX SODIUM

  • Indication: Treatment of unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI).

ENOXAPARIN SODIUM

  • Indication: Prophylaxis of DVT (deep vein thrombosis) and PE (pulmonary embolism).
  • CLEXANE® is the brand of choice in Primary and Secondary care. Brand prescribing is recommended to ensure continuity of device supply.
  • INHIXA® continues to be the preferred brand of enoxaparin for MATERNITY patients discharged from University Hospital Wishaw only.

TINZAPARIN SODIUM

  • Indications:
    • Inpatient treatment of DVT and PE. For outpatients APIXABAN is the recommended treatment (see Prescribing Notes below).
    • Extended treatment of venous thromboembolism and prevention of recurrences in adult patients with active cancer.

 

Specialist use only (S2)

HEPARIN (UNFRACTIONATED)

Oral Anticoagulants

Preferred list (P)

WARFARIN SODIUM

  • WARFARIN is a synthetic anti-coagulant of the coumarin series and acts by inhibiting the synthesis of vitamin K dependent clotting factors, which include Factors II, VII, IX and X, and the anticoagulant proteins C and S.
  • ONCE DAILY DOSING, AT THE SAME TIME EACH DAY.

EDOXABAN

  • EDOXABAN is a direct and reversible inhibitor of activated factor X (factor Xa), which prevents conversion of prothrombin to thrombin and prolongs clotting time, thereby reducing the risk of thrombus formation.
  • ONCE DAILY DOSING.

 

Total list (T)

APIXABAN

  • APIXABAN is a direct inhibitor of activated factor X (factor Xa).
  • TWICE DAILY DOSING.

 

Specialist use only (S2)

RIVAROXABAN

  • RIVAROXABAN is a direct inhibitor of activated factor X (factor Xa).
  • Restricted use:
    1. Venous thromboembolism (VTE) prophylaxis in trauma and orthopaedic surgery.
    2. VTE prophylaxis in ambulatory trauma (Emergency Department).
      N.B. off label use.
  • ONCE DAILY DOSING.
  • Duration dependent on indication.
  • Please refer to local guidance (links below).

Prescribing Notes:

Atrial Fibrillation (AF)

Treatment of Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE)

Venous thromboembolism (VTE) Prophylaxis in Trauma and Orthopaedic Surgery

VTE Prophylaxis in Ambulatory Trauma (Emergency Department)

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.