LMWH and anti-Xa in ACS

[spacecowgirl]

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Hospital pharmacists - what are your protocols for Arixtra and or Fragmin in ACS? We got rid of Lovenox and you would think that it was the apocalypse and everyone is confused. The data I've found for dalteparin shows using 120units/kg sub-q q 12. I'm curious to know what others are doing/recommending for ACS.

 

[ItsOverZyvox]

Hospital pharmacists - what are your protocols for Arixtra and or Fragmin in ACS? We got rid of Lovenox and you would think that it was the apocalypse and everyone is confused. The data I've found for dalteparin shows using 120units/kg sub-q q 12. I'm curious to know what others are doing/recommending for ACS.

Arixtra 2.5 mg SQ daily for STEMI

Fragmin 120u/kg Q12h with 10,000 unit max per dose for NSTEMI.

Congratulations. That is fantastic what you guys are doing. You guys will also save a lot of money...if you were spending $1,000,000 per year on Lovenox, then you'll spend $500,000 to $600,000 on Arixtra and Fragmin.

so, Lovenox 60mg BID = Fragmin 7500 U BID
Lovenox 70mg BID = Fragming 8500 U BID
Lovenox 80mg BID and above = Fragmin 10,000 U BID.

For Arixtra, read OASIS V and VI.

 

[spacecowgirl]

Thanks Zpack (you'll always be Zpack to me).

What are some of the studies for Fragmin, that's where I'm running into problems. Also, we're using weight-based dosing for ACS up to 10 mg for pts > 100kg. Hmmm.

 

[ItsOverZyvox]

Thanks Zpack (you'll always be Zpack to me).

What are some of the studies for Fragmin, that's where I'm running into problems. Also, we're using weight-based dosing for ACS up to 10 mg for pts > 100kg. Hmmm.

10mg for Arixtra?? Why? OASIS showed that 2.5mg was just as effective yet with less bleeding than Lovenox 1mg/kg q12h.

ESSENCE showed that Lovenox 1mg/kg q12h was more effective than IV heparin. This was the landmark study that catapaulted Lovenox.

FRIC (Fragmin in Unstable Coronary Artery Disease) showed that fragmin was as efficacious as IV Heparin...

But if you read both studies carefully, you'll see that the IV heparin in FRIC was very aggressive. Also, FRIC was a European study with less critical patients vs ESSENCE was a North American Study with sicker patients. Mass General, a study site for ESSENCE (Lovenox study) used Fragmin as their LMWH of choice for the logest time until recently when Aventis gave them a sweet heart pricing deal on Lovenox.

Unfortunate thing is, Arixtra doesn't have the ACS indication in the US.

I'm not sure you'll find a decent copy of FRIC.. I may have an electronic copy... if you need it PM me..

 

[spacecowgirl]

2.5 is our DVT prophylaxis dose. I don't know why. I'm still learning this inpatient world. PM coming...

 

[ItsOverZyvox]

2.5 is our DVT prophylaxis dose. I don't know why. I'm still learning this inpatient world. PM coming...

Y'all are doing it wrong then. I'm going to send you the OASIS article also then.

 

[acetyl]

2.5 is our DVT prophylaxis dose. I don't know why. I'm still learning this inpatient world. PM coming...

I was told 2.5 mg SQ q24h Arixtra for VTE prevention and 10 mg SQ q24h(pt >100 kg) for VTE treatment...this not correct Z?

 

[ItsOverZyvox]

I was told 2.5 mg SQ q24h Arixtra for VTE prevention and 10 mg SQ q24h(pt >100 kg) for VTE treatment...this not correct Z?

That's correct.

But for Acute Coronary Syndrome, it's 2.5mg SQ q24h.

 

[nikkai]

For those without access to JAMA:

Quick & dirty Oasis V

Quick & dirty Oasis VI

Medscape has its uses sometimes - but I recommend going to the original article when possible.

 

[ItsOverZyvox]

For those without access to JAMA:

Quick & dirty Oasis V

Quick & dirty Oasis VI

Medscape has its uses sometimes - but I recommend going to the original article when possible.

Can you summarize each trial in bullet points please? Thank you.

 

[nikkai]

Can you summarize each trial in bullet points please? Thank you.

Sure thing.

• Oasis V: Stop being biased toward Lovenox
• Oasis VI: Stop being biased toward UFH
• Oasis VI: PCI 'fo life!
• 

 

[ItsOverZyvox]

Sure thing.

• Oasis V: Stop being biased toward Lovenox
• Oasis VI: Stop being biased toward UFH
• Oasis VI: PCI 'fo life!
• 

Good Job! 👍

 

[acetyl]

That's correct.

But for Acute Coronary Syndrome, it's 2.5mg SQ q24h.

So for someone with STEMI, you would use a thrombolytic and fondaparinux instead of UFH? With IIb/IIIa inhibitor and PCI too

 

[ItsOverZyvox]

So for someone with STEMI, you would use a thrombolytic and fondaparinux instead of UFH? With IIb/IIIa inhibitor and PCI too

For STEMI patients...they should head over to cath ASAP..

But if you were to use enoxaparin, then sub it with Arixtra 2.5mg. OASIS V is a must read for you.

 

[acetyl]

For STEMI patients...they should head over to cath ASAP..

But if you were to use enoxaparin, then sub it with Arixtra 2.5mg. OASIS V is a must read for you.

Dude have you ever seen a really nasty bruise from a PCI on someone's leg? That is crazy sometimes...a huge hematoma!

And for real...when is TW coming back? His website says TBA...that is garbage, tell us when!

 

[ItsOverZyvox]

Dude have you ever seen a really nasty bruise from a PCI on someone's leg? That is crazy sometimes...a huge hematoma!

And for real...when is TW coming back? His website says TBA...that is garbage, tell us when!

TW will be back for the Masters.

 

[acetyl]

TW will be back for the Masters.

You ever played the South course at Torrey Pines?

Been there twice. All the way back that course is crazy hard. Into the wind couldn't reach #12 in two with well hit driver and 3-wood.

 

[ItsOverZyvox]

You ever played the South course at Torrey Pines?

Been there twice. All the way back that course is crazy hard. Into the wind couldn't reach #12 in two with well hit driver and 3-wood.

No never...

 

[JeremyE30]

We switched over to Fragmin also. I bet we are losing money b/c nurses lose about 50% of the Fragmin syringes that I draw from the stock vial. I don't know what they are doing with them. We have the factory syringes but there are volumes that have to be made in the IV room, and then lost on the floor, and made again.

 

[ItsOverZyvox]

We switched over to Fragmin also. I bet we are losing money b/c nurses lose about 50% of the Fragmin syringes that I draw from the stock vial. I don't know what they are doing with them. We have the factory syringes but there are volumes that have to be made in the IV room, and then lost on the floor, and made again.

You're doing it right. Drawing up those doses from the 9ml multidose vial. Look at it this way, if they're losing your fragmin syringes, they were losing the Lovenox syringes too... right? So no worries.

 

[JeremyE30]

You're doing it right. Drawing up those doses from the 9ml multidose vial. Look at it this way, if they're losing your fragmin syringes, they were losing the Lovenox syringes too... right? So no worries.

We didn't have to draw up Lovenox. We strictly used the pre-filled syringes that come from the acudose 40, 60, 80mg etc.

I think by the time I make the frag syringe, rph checks it, other pharm tech lets it sit on the counter for 30 min, next pharm tech tubes it up 3 floors, unit secretary checks the tube 30 min later - lays syringe under other piles of paper/meds, syringe gets lost somewhere along the way.

Plus, with the pre-filled syringes, if it is lost and then found later on the next day, as long as it wasnt opened then it is still good. The frag syringes are only good for 48hrs.

IDK, i guess we are saving money.

 

[ItsOverZyvox]

We didn't have to draw up Lovenox. We strictly used the pre-filled syringes that come from the acudose 40, 60, 80mg etc.

I think by the time I make the frag syringe, rph checks it, other pharm tech lets it sit on the counter for 30 min, next pharm tech tubes it up 3 floors, unit secretary checks the tube 30 min later - lays syringe under other piles of paper/meds, syringe gets lost somewhere along the way.

Plus, with the pre-filled syringes, if it is lost and then found later on the next day, as long as it wasnt opened then it is still good. The frag syringes are only good for 48hrs.

IDK, i guess we are saving money.

Trust me. You're saving money... wastage isn't as bad as you think.

 

[spacecowgirl]

Y'all are doing it wrong then. I'm going to send you the OASIS article also then.

I was told 2.5 mg SQ q24h Arixtra for VTE prevention and 10 mg SQ q24h(pt >100 kg) for VTE treatment...this not correct Z?

That's what we're doing too - but you said it was wrong, but then..

That's correct.

But for Acute Coronary Syndrome, it's 2.5mg SQ q24h.

I'm confused.

Why such a low dose for ACS do you think?

 

[spacecowgirl]

Oh I see what you're saying. The weight-based is only for VTE, it's across the board 2.5 for ACS. Nevermind.

But I'm still more interested in the use of Fragmin in ACS because our policy actually says "not for use in ACS".

 

[ItsOverZyvox]

Oh I see what you're saying. The weight-based is only for VTE, it's across the board 2.5 for ACS. Nevermind.

But I'm still more interested in the use of Fragmin in ACS because our policy actually says "not for use in ACS".

Fragmin does not have STEMI indication to begin with. Strike one.
FRIC study showed Fragmin was equivalent to Heparin while ESSENCE showed Lovenox was superior to Heparin, Strike two.
The latest chest guideline actully recommends Enoxaparin for STEMI... where it used to generically say LMWH.. I think. Strike 3...

That being said, I have no issue using Fragmin.. 120u/kg SQ Q12h with 10,000 units max per dose.. with the contract.. 10,000 unit costs around 32 bucks..so $64 per day.. compare that to 80mg Lovenox..around $45 to $50 per dose.. $90 to $100, per day. You save more money if you convert 100mg + dose lovenox to Fragmin...

 

[ItsOverZyvox]

Why such a low dose for ACS do you think?

Because it worked well in OASIS.

 

[spacecowgirl]

Got your emails, thanks Z.

 

[ItsOverZyvox]

Got your emails, thanks Z.

You just got it? I sent it like 10 days ago!