Intradialytic anticoagulation

[Kim Defoe]

Hi all,

We are currently in the process for changing our intradialytic anti-coagulation from UFH to tinzaparin. I wanted to see how many other centres have switched over and what their experience has been?

Are other centres administering through the arterial or venous ports? I can only find one resource that says that tinz can be dialyzed out with high flux dialyzers but we are considering trying through the venous port on the theory that tinz could be dialyzed out if administered arterial so perhaps we can get away with a lower dose for effective anti-coagulation. One of our physicians mentioned a paper from Australia (that he can’t find now…) and I can’t find any evidence to support this…

Are other centres using a weight based dose banding approach, a standard starting dose or a UFH conversion?

Look forward to hearing from everyone!

[Derrick Soong]

Sorry this is a very late response … but it seems most Ontario sites are using dalteparin (Fragmin). I would assume tinzaparin (Innohep) is equally efficacious (used extensively in UK and other parts of Canada).

It would seem logical to go through the arterial port so you’d “coat” the dialysis filter and potentially minimize systemic absorption. But there is good reason to try the venous side to minimize drug wastage.

I’m not aware of any dosing studies comparing arterial VS venous side administration. It might be a great research project … 😉

We originally adopted Toronto Eastern’s weight based protocol when we converted from UFH to LMWH but from our own clinical experience, it seems almost everyone starting hemodialysis tolerates the starting dose 2500 IU of dalteparin regardless of weight. I would assume the starting tinzaparin dose would work equally well.

Good luck with everything.

– Derrick Soong, RPh (Windsor Regional Hospital)

PS  What did you end up doing?  How did that work out?

[Stephanie Giles]

G’day from Alice Springs, Australia,

Our renal dialysis centres have patients on enoxaparin- either 20mg or 40mg pre dialysis through the venous port. Mentioned below is the paper that I think you are talking about, Kim. We changed appropriate patients over to enoxaparin this time last year after a huge heparin shortage (that was our only anticoag at the time for Intradialytic anticoagulation). When we first introduced the change, we administered via the arterial port, however we found we were dumping a lot of circuits. We moved over to the venous line and we have had much success. We use a weight based approach- being 40kg-85kg: 20mg enoxaparin pre HD via the venous port and 85.1kg-110kg- 40mg enoxaparin pre HD via the venous port. Enoxaparin’s PI states for administration via the arterial port only in HD- therefore I am trying to collate the results we have (retrospectively) and put together a case.

https://www.ncbi.nlm.nih.gov/pubmed/26609786

Arterial line versus venous line administration of low molecular weight heparin, enoxaparin for prevention of thrombosis in the extracorporeal blood circuit of patients on haemodialysis or haemodiafiltration: A randomized cross-over trial.

Thanks,

Stephanie Giles- Senior Renal Pharmacist, Alice Springs Hospital

 

 

[Stephanie Gilbreath]

We have an inpatient who receives dalteparin 5000units via HD arterial port for ECC anticoagulation (three times weekly).  Prescriber wants to put him on DVT prophylaxis which at our hospital is generally Fragmin 5000units SC daily or maybe for him, heparin 5000 units bid since he’s a hemo patient.  It’s not clear to me how much systemic absorption there is of LMWHs when administered via arterial port.  Is it your practice to give DVT prophylaxis 7 days per week despite a high dose ECC anticoagulant? Thanks!

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