Pharmacological targets, main clearance pathways and UK licensed indications of parenteral anticoagulants
| Anticoagulant | Target | Main clearance pathway | UK indications | Adjustment for renal impairment |
|---|---|---|---|---|
| Unfractionated heparin (SC and IV) | Inhibition of thrombin and factor X through AT | Reticuloendothelial system | VTE ACS APAO | No dose adjustment for ACS Other indications reduce dose by 33% if CrCl <15 mL/min Subsequent APTT adjusted dosing |
| Enoxaparin (SC only) | Inhibitor of factor Xa, IIa and thrombin through AT | Renal | VTE | No dose adjustment for PE Reduce dose by 50% if CrCl <30 mL/min Not recommended if CrCL <15 mL/min Consider anti-Xa adjusted dosing for prolonged treatment (anti-Xa:IIa ratio 3.9) |
| Tinzaparin (SC only) | Inhibitor of factor Xa and other coagulation factors through AT | Renal | VTE | Not needed Consider anti-Xa adjusted dosing for prolonged treatment (anti-Xa:IIa ratio 2.8) |
| Dalteparin (SC only) | Inhibitor of factor Xa, thrombin through AT | Renal | ACS VTE | Not needed |
| Fondaparinux (SC only) | Selective inhibitor of factor Xa through AT | Renal | VTE ACS | Reduce dose by 50% if CrCl 30–50 mL/min VTE: do not use if CrCl <30 mL/min ACS: do not use if CrCl <20 mL/min |
| Argatroban (IV only) | Direct thrombin inhibitor | Faeces | HIT | Not needed (renal clearance <15%); APTT monitoring required |
| Bivalirudin (IV only) | Direct thrombin inhibitor | Renal | ACS | Do not use if CrCL <30 mL/min |
| Danaparoid (SC and IV) | Selective inhibitor of factor Xa through AT | Renal | HIT | Avoid if CrCL <30 mL/min or in dialysis patients unless no alternative to manage HIT available |
The dose adjustments suggested are for guidance only and the reader is directed to local protocols and formularies for definitive dosing. ACS = acute coronary syndrome; APAO = acute arterial peripheral occlusion; APTT = activated partial thromboplastin time; AT = antithrombin; CrCl = creatinine clearance rate; HIT = heparin induced thrombocytopenia; IV = intravenous; PE = pulmonary embolism; SC = subcutaneous; VTE = venous thromboembolism.