II. Low-Range Heparin Administration Orders (pdf)

III. Guidelines for Management of Full Intensity SQ

1. FIXED DOSING: UFH 250 U/kg SQ q12h with no aPTT monitoring
   (consider 333 U/kg SQ loading dose for treatment of acute thrombosis)
   (do not use for treatment/prevention of arterial thrombosis [eg: AF, valve replacement, etc])
   
   
2. ADJUSTED DOSE:

• Initial Dosing

1. Initial therapy with adjusted-dose SQ UHF
   1. give UHF 240 U/kg SQ x 1
   2. check aPTT 6 hours after first dose
   3. adjust dosing according to chart below
2. Conversion from continuous infusion UFH to adjusted dose SQ UFH
   1. calculate 24hrs dosing requirement necessary to maintain therapeutic aPTT
   2. divide into two q12h doses
   3. discontinue IV UFH and administer first SQ dose within 1 hours
   4. check first aPTT 6 hours after first dose
   5. adjust dosing according to chart below
3. Conversion from warfarin to adjusted dose SQ UFH
   1. discontinue warfarin
   2. give UFH 240 U/kg SQ when INR < lower limit of therapeutic range
   3. check aPTT 6 hours after first dose
   4. adjust dosing according to chart below

• Maintenance Dosing Adjustments

  aPTT (sec) (based on reagent with tx range 60-100)	Dosing Adjustment (rounded to nearest 500 units)	Next aPTT
  < 40	Increase dose by 36-48 U/kg q 12h	6 hrs after a dose in 1-3 days
  40-59	Increase dose by 24-36 U/kg q 12h	6 hrs after a dose in 1-3 days
  60-100	No change	q 4-7 days (6 hrs after a dose)
  101-120	Decrease dose by 6-12 U/kg q 12h	6 hrs after a dose in 1-3 days
  121-140	Decrease dose by 12-24 U/kg q 12h	6 hrs after a dose in 1-3 days
  >140	Decrease dose by 24-36 U/kg q 12h	6 hrs after a dose in 1-3 days

• REQUIRED MONITORING FOR EITHER OPTION
  
  • Baseline: plts, HCT, PT/INR, aPTT
  • First 2 weeks of UFH: plts q 2-3 days
  • Ongoing therapy: plts, HCT q 2-4 weeks