MI L
Volume 7, No. 10
October 2014
This Medicines Information Leaflet is produced locally to optimise the use of medicines by encouraging prescribing
that is safe, clinically appropriate and cost-effective to the NHS.
Treatment of VTE with dalteparin (Fragmin®) in patients with cancer
E
vidence has shown that patients with active
cancer, or patients undergoing cancer treatment
have lower rates of VTE recurrence when treated
with low molecular weight heparin (LMWH)
instead of warfarin, without increasing the risk of
bleeding.
This document focuses on the doses of subcutaneous
dalteparin for cancer patients, and which patients
should be excluded from this regimen. For all other
clinical information with respect to dalteparin for the
treatment of VTE, please see MIL Vol 2 No 2 Treatment
of venous thromboembolism (VTE) in adults with
dalteparin (Fragmin®).
Patient exclusions
For patients to be considered for extended treatment
with dalteparin, they must be able to self-inject, or
have a carer who can inject for them. If they are not
able to, they will be treated as for non-cancer patients.
Patients with significant renal impairment (creatinine
clearance less than 30mL/min) should be discussed with
a Haematology SpR (bleep 5529).
Patients who weigh less than 40kg are excluded from
the product license and should be discussed with a
Haematology SpR (bleep 5529) before extended
treatment is initiated.
Dose and administration
Month 1
Body weight (kg)
Less than 46
Dose (units)
7,500 once daily
46-56
10,000 once daily
57-68
12,500 once daily
69-82
15,000 once daily
83-120
18,000 once daily
121-131
12,500 twice daily
132-143
15,000 mane & 12,500 nocte
144-157
15,00 twice daily
158-172
18,000 mane & 15,000 nocte
More than 172
18,000 twice daily
Medicines Management and Therapeutics Committee
Oxford University Hospitals
In
the
case
of
chemotherapy-induced
thrombocytopenia, the dose should be adopted as
follows:
9
For platelet counts between 50-100 x 10 /L, the
manufacturer recommends that the dose should be
reduced by 2,500units until the platelet count recovers
9
to greater than or equal to 100 x 10 /l. However, a risk
benefit assessment may favour continuing full dose
anticoagulation.
9
For platelet counts below 50 x 10 /L, the manufacturer
suggests that dalteparin should be withheld until the
platelet count recovers to greater than or equal to 50 x
9
10 /L. However, a risk benefit assessment may favour
continuing a 50% dose of dalteparin for counts between
9
25 and 50 x 10 /L. If anticoagulation is discontinued an
IVC filter should be considered.
Months 2-6
Body weight (kg)
Less than 57
Dose (units)
7,500 once daily
57-68
10,000 once daily
69-82
12,500 once daily
83-98
15,000 once daily
More than 98
18,000 once daily
In
the
case
of
chemotherapy-induced
thrombocytopenia in the extended treatment phase
(months 2-6, consult product literature or contact
Haematology for advice on bleep 5529).
Duration of treatment
Licensed duration of treatment is 6 months. A local
shared-care agreement exists between primary and
secondary care for supplying dalteparin. For patients in
whom long term anticoagulation is indicated, discuss
with the haematology registrar/consultant at the
Oxford Anticoagulation Service.
References
1. Lee AYY et al Low molecular weight heparin versus a coumarin for
the prevention of recurrent venous thromboembolism in patients
with cancer. NEJM 349 146-153
2. Summary of Product Characteristics (SPC) for dalteparin
(Fragmin®), Pfizer limited. Accessed via www.medicines.org.uk 18th
October 2014
October 2014
2
3. British National Formulary (BNF) 63rd Ed. British Medical
Association and the Royal Pharmaceutical Society of Great Britain,
London, UK. March 2014
4. Venous thromboembolic diseases: the management of venous
thromboembolic diseases and the role of thrombophilia testing NICE
CG144, June 2012
5. Antithrombotic and Thrombolytic Therapy, 9th Ed: ACCP
Guidelines. Chest 141 supplement, 2012
Prepared by:
Vicki Price, Lead Pharmacist, Anticoagulation & Thrombosis
Pharmacist & Dr. David Keeling, Consultant Haematologist
Review date: October 2017
Medicines Information Leaflet