Heparin

LMWH is treatment of choice in most cases as low risk of HITT (heparin-induced thrombocytopenia with thrombosis), given by SC injection and usually does not require monitoring or dose adjustment. Indicated for prevention and treatment of VTE and acute coronary syndromes.

If UFH is given then IV infusion should be monitored by regular APTT measurement, at least once daily. APTT ratio usually maintained at 1.5-2.5 x normal.

HITT is an uncommon complication but high risk of death and limb amputation. Should be considered if 50% reduction in platelet count whilst on heparin therapy. Difficult to confirm diagnosis with lab tests so diagnosis should be made on clinical suspicion. Treatment is to stop all heparin, including flushes, and give direct thrombin inhibitor such as recombinant hirudin or danaparoid (non-heparin activator of antithrombin). HITT can complicate low dose as well as therapeutic doses of heparin.

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