Denumire

Ad
mi
n
Heparina standard s.c
i.v.
P: boala
!!
tromboembolica
NUi
venoasa
.m.
T:TVP
SCA +supradenivelare
AVC ischemic
FIA
Proteza valva
mecanica
Embolie pulmonara
Embolie arteriala

LMWH
Clexane/Enoxaparin
a
Fragmine/Dalteparin
a
Fraxiparina/Nadropa
rina
Innohep/Tinzaparina
P:boala
tromboembVenos
T:TVP

Tim
p
1/2
1-2
ore

Monitorizare

Efecte
adverse

APTT
N=25-40 sec
Terapeutic=5570sec
Cand:la 4-6 ore
de la initiere
tratament /
modificare doza

Hemoragii
Heparine
induced
thrombocytope
nia:
HITtip1-benign
HITtip2tromboze
art./venos!!

Nu necesita
Nivel anti Xa

Risc mai mic

de hemoragii

Antidot

Se
leaga
de
Sulfat
Antiprotamin trombin
e
a
1mg IV
per 100U
(daca
administr
at in
ultimele
30 min);
0,5mg
IV /100U
(3060min)l
0,25mg IV
(>2ore)
! Reactie
anafilacti
a
!hipoTA
Sulfat
Antiprotamin trombin
e
a
Clexane:
1mg
IV/1mg
Fragmine:
1mgIV/10
0U
!Reactie
anafilacti
ca

Inhiba

Doza

Excret
ie

f Xa
f IIa/
Trombin
a

Tratament:
depinde de
protocol;
Profilaxie: 5000
U sc la 12 ore
(obezi la 8 ore)

Hepati
c
(Nu se
ajustea
za
dozele
in insuf
renala)

f Xa > f
IIa

Clexane:
P:40mg/zi s.c.;
IR: 30mg/zi sc
T:1,5mg/kg/zi
sc sau 1mg/kg
s.c. BID in
SCA/obezitate
IR:1mg/kg/zi
s.c.
Fragmine:
P: 5000U s.c.
T:200U/kg s.c.

Renal

Embolie pulm
necomplic
SCA FARA
supradeniv ST
permanenta
Arixtra/Fondaparin
ux

!hipoTA

Nu necesita

CI:
CrCl<30mL/mi
n

INR
(PTstandardizat)
Target:
FIA, TVP,EP=2-3
Valva
mecanica=3-3,5

Hemoragii
CI: Alzheimer,
psihoze

f Xa

P:b. tromboemb
venoasa
T:TVP
Embolie pulm
SCA-supradeniv
perm ST
HIT

Sintrom
AVK

Plasma
proaspat
a
congelat
a daca
sangere
aza
15ml/kg
efect
rapid
Vitamina
K per os
efect lent
si de
durata 1-

Factorii
depend
enti de
vit K:
II, VII,
IX, X

Profilactic:2,5m
g/zi
Curativ:
NSTEMI
2,5mg/zi
STEMI cu
tromboliza
2,5mg i.v. apoi
2,5mg s.c.
TVP/EP:
5mg <50kg
7,5mg 50100kg
10mg >100kg
Initiere 1-2 tb/zi
doza: batrani,
insuf hepatica,
IC, risc
hemoragic
crescut
Nu necesita
ajustare doza
in insuficienta
renala
INR initial: zi 3

2 sapt
(nu se
foloseste
daca se
va reinitia
terapia cu
Sintrom)
Sangerea
za: 510mg IV
in 30min
!
Anafilaxie
Xarelto/Rivaroxaba
n
P:TVP
AVC
Embolie sistemica
FIA
T:TVP fara EP
simptomatica
Pradaxa/Dabigatra
n
P:AVC
Embolie sistemica
FIA

5-13
h

Nu necesita

CI:CrCl<30ml/
min
+ risc
hemoragii
intracraniene

Nu exista

f Xa

FIA:20mg po
TVP tratament:
15mg BID 3
sapt, apoi
20mg/zi

Renala

1217h

Nu necesita;
aPTT modificat:
prezenta
semnificativa a
med;
PT normal: 0
med;

CI:CrCl<30ml/
min
+ risc
hemoragii
intracraniene

Nu exista

f IIa/
Trombin
a

FIA:150mg BID;
110mg BID
daca >75ani
sau la p cu risc
hemoragic

Renala

f Xa

TVP 2,5mg BID

Eliquis/Apixaban
9-12
P:TVP
h
FIA
Conversie Heparina nefractionata -> LMWH:
Initiere LMWH la 1-2 ore DUPA terminare heparina nefractionata
Conversie LMWH->Heparina nefractionata:

Initiere Heparina nefractionata la 6- 12 ore DUPA ultima doza LMWH

Conversie Heparina nefractionata -> Dabigatran/Rivaroxavan:
Imediat dupa terminare heparina nefractionata
Conversie Dabigatran/Rivaroxaban ->Heparina nefractionata:
CrCl: 30-50ml/min: initiere Heparina nefract la 24 ore DUPA ultima doza de Dabig/Rivarox
CrCl: >50ml/min: initiere Heparina nefract la 12 ore DUPA ultima doza Dabig/Rivarox
Conversie LMWH->Dabigatran/Rivaroxaban:
Initiere la 6 ore dupa ultima doza de LMWH
Conversie Dabigatran/Rivaroxaban -> LMWH:
CrCl: 30-50ml/min: la 12-24 ore dupa ultima doza de Dabigatran/Rivaroxaban
CrCl: >50ml/min: la 6-12 ore dupa ultima doza de Dabigatran/Rivaroxaban
Conversie Sintrom -> Dabigatran/Rivaroxaban:
Initiere la 4 zile dupa ultima doza de Sintrom sau cand INR < 2
Conversie Dabigatran/Rivaroxaban->Sintrom:
CrCl: 30-50ml/min: initiere Sintrom cu 4 zile inainte de ultima doza de Dabigatran/Rivaroxaban
CrCl: >50ml/min: initiere Sintrom cu 2 zile inainte de ultima doza de Dabigatran/Rivaroxaban
Conversie de pe Heparina pe Sintrom: Sintrom se administreaza concomitant cu Heparina (Heparina se administreaza MINIM
4 zile). Time to peak - efect antitrombotic pentru Sintrom e de 96 ore. Cand INR e in interval therapeutic, intrerupi Heparina
Sintrom se initiaza cu 1 tb
Ajustare doza Sintrom in functie de INR:
<2: doza saptamanala cu 10-20%
2-3: 3-4: doza saptamanala cu 10-20%
4-6: omite o doza; apoi reincepe cu o doza mai mica
6-10: omite 2 doze; INR la 48 ore
>10:administreaza 2.5mg Vitamina K
FIA: AVK, anticoagulante orale noi
Tromboza venoasa profunda/EP: standard Sintrom + heparina nefractionata/LMWH initiat concomitant. Heparina minim 5 zile
concomitant cu Sintrom. Poate fi intrerupta (Heparina) daca INR 2 zile consecutive >2;
Alternativa la TVP fara EP: Rivaroxaban
Tromboza venoasa + sarcina = LMWH pe timpul sarcinii + 6 sap postpartum
!!! Sintrom Contraindicat
Tromboza venoasa + neoplazie = primele 6 luni LMWH, apoi LMWH/Sintrom