Dosing & Uses
Dosage Forms & Strengths
injectable solution, single-dose prefilled syringe
- 2,500 IU/0.2 mL
- 5,000 IU/0.2 mL
- 7,500 IU/0.3 mL
- 12,500 IU/0.5 mL
- 15,000 IU/0.6 mL
- 18,000 IU/0.72 mL
injection, single-dose graduated syringe
- 10,000 IU/mL
injection, multiple-dose vials
- 95,000 IU/3.8 mL (25,000 IU/mL)
Unstable Angina and Non-Q-Wave Myocardial Infarction
Indicated for prophylaxis of ischemic complications in unstable angina and non-Q-wave myocardial infarction, when concurrently administered with aspirin therapy
120 IU/kg total body weight (TBW) SC q12hr with concurrent oral aspirin (75-165 mg qDay) therapy; not to exceed 10,000 IU q12hr
Continued until patient is clinically stabilized
Usual duration of administration: 5-8 days
Concurrent aspirin therapy is recommended except when contraindicated
Weight-based dosing
- <50 kg: 5500 IU SC q12hr
- 50-59 kg: 6500 IU SC q12hr
- 60-69 kg: 7500 IU SC q12hr
- 70-79 kg: 9000 IU SC q12hr
- ≥80 kg: 10,000 IU SC q12hr
Deep Vein Thrombosis
Indicated for prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE) in patients undergoing hip replacement, in patients undergoing abdominal surgery who are at risk for thromboembolic complications, and in medical patients who are at risk for thromboembolic complications due to severely restricted mobility during acute illness
Hip replacement surgery
- 10-14 hr before surgery: 5000 IU SC preoperative; start the evening before surgery; allow ~24 hr between doses OR
- Within 2 hr before surgery: 2500 IU SC preoperative; start day of surgery
4-8 hr after surgery
- Postoperative start: 2,500 IU SC
- Preoperative start, day of surgery: 2,500 IU SC
- Preoperative start, evening before surgery: 5,000 IU SC
- Allow at least 6 hr between this dose and dose to be given on postoperative Day 1
- Adjust timing of dose on postoperative Day 1 accordingly
Postoperative period
- Postoperative start: 5,000 IU SC qDay
- Preoperative start, day of surgery: 5,000 IU SC qDay
- Preoperative start, evening before surgery: 5,000 IU SC qDay
- Usual duration of treatment was 5-10 days postoperatively; up to 14 days of treatment was well tolerated in clinical trials
Abdominal surgery
Patients with a risk of thromboembolic complications
- 2,500 IU SC qDay, starting 1-2 hr prior to surgery and repeated qDay postoperatively
- Usual duration of administration is 5-10 days
Patients with a high risk of thromboembolic complications (eg, malignant disorder)
- 5,000 IU SC the evening before surgery, THEN qDay postoperatively
- Usual duration of administration is 5-10 days
- Alternatively, in patients with malignancy, 2,500 IU SC 1-2 hr before surgery followed by 2,500 IU SC 12 hr later, and then 5,000 IU qDay postoperatively
- Usual duration of administration is 5-10 days
Patients with severely restricted mobility during acute illness
- 5,000 IU SC qDay
- In clinical trials, usual duration of administration was 12-14 days
Venous Thromboembolism in Patients with Cancer
Indicated for extended treatment of symptomatic venous thromboembolism (VTE) (proximal DVT and/or PE), to reduce recurrence of VTE in adult patients with cancer
In these patients, begin therapy with initial VTE treatment and continues for 6 months
Month 1
- Administer 200 IU/kg TBW SC qDay; total daily dose should not exceed 18,000 IU
- ≤56 kg: 10,000 SC qDay
- 57-68 kg: 12,500 SC qDay
- 69-82 kg: 15,000 SC qDay
- ≥83 kg: 18,000 SC qDay
Months 2-6
- Administer at a dose of ~150 IU/kg SC qDay during Months 2-6; total daily dose should not exceed 18,000 IU
- ≤56 kg: 7,500 SC qDay
- 57-68 kg: 10,000 SC qDay
- 69-82 kg: 12,500 SC qDay
- 83-98 kg: 15,000 SC qDay
- ≥99 kg: 18,000 SC qDay
Anticoagulation Therapy (Off-label)
200 IU/kg SC qDay or 100 units/kg SC q12hr
Dosage Modifications
Dose reductions for thrombocytopenia in patients with cancer
- Platelets ≥50,000/mm³: Discontinue dalteparin until platelet count recovers to >50,000/mm³
- Platelets 50,000-100,000/mm³: Reduce daily dose by 2500 units until 100,000/mm³
Renal impairment (VTE in adult patients with cancer)
- Severe (CrCl<30 mL/min): Monitor anti-Xa levels to determine appropriate dose; target anti-Xa range is 0.5-1.5 IU/mL; perform sampling 4-6 hr after dosing and only after patient has received 3-4 doses
Dosing Considerations
Limitation of use: Not indicated for acute treatment of VTE
Other Indications & Uses
Symptomatic venous thromboembolism (DVT/PE) treatment to reduce recurrence in patients with cancer
Off-label: Treatment of thromboembolism during pregnancy, DVT prophylaxis during knee replacement surgery, neurosurgery, trauma, burns, pediatric
Dosage Forms & Strengths
injectable solution, single-dose prefilled syringe
- 2,500 IU/0.2 mL
- 5,000 IU/0.2 mL
- 7,500 IU/0.3 mL
- 12,500 IU/0.5 mL
- 15,000 IU/0.6 mL
- 18,000 IU/0.72 mL
injection, single-dose graduated syringe
- 10,000 IU/mL
injection, multiple-dose vials
- 95,000 IU/3.8 mL (25,000 IU/mL)
Venous Thromboembolism
Indicated for treatment of symptomatic venous thromboembolism (VTE) to reduce the recurrence of VTE in pediatric patients ≥1 month
<4 weeks: Safety and efficacy not established
4 weeks to <2 years: 150 IU/kg SC BID
2 to <8 years: 125 IU/kg SC BID
8 to <17 years: 100 IU/kg SC BID
Dosage Modifications
Dose reductions for thrombocytopenia
- Platelets ≥50,000/mm³: Discontinue dalteparin until platelet count recovers to >50,000/mm³
- Platelets 50,000-100,000/mm³: Reduce daily dose by 50% until 100,000/mm³
Dosing Considerations
Limitation of use: Not indicated for acute treatment of VTE
After initiation
- Measure anti-Xa level prior to 4th dose
- Draw samples for anti-Xa level 4 hr after administration
- Adjust doses in increments of 25 IU/kg to achieve target anti-Xa level at 0.5-1 IU/mL
- Individualize maintenance dose based on the dose that achieves target anti-Xa level collected 4 hr
- Monitor anti-Xa level periodically in pediatric patients to maintain anti-Xa level at 0.5-1 IU/mL
Extended VTE Treatment in Patients with Cancer
200 units/kg SC qDay for 30 days, THEN
Months 2-6: 150 units/kg SC qDay
Not to exceed 18,000 units daily
Treatment Duration: 5-10 days usual
Severe mobility restriction: 5000 units SC qDay
Unstable angina and non-Q-wave MI
120 IU/kg SC q12hr for 5-8 days (concurrent with aspirin 75-165 mg qDay)
Not to exceed 10,000 units/dose or 18,000 units/day
Treatment duration: Continue until patient stabilized; 5-10 days usual
Deep vein thrombosis prophylaxis for hip replacement
PostOp Start: 2500 units SC 4-8 hr postsurgery, THEREAFTER 5000 units qDay
PreOp Start: On day of surgery: 2500 IU SC within 2 hours presurgery, THEN
2500 units SC 4-8 hr postsurgery, THEREAFTER 5000 units SC qDay (administration: At least 6 hr between first post-op dose & Post-op Day 1 dose)
Evening before surgery: 5000 units SC 10-14 hr presurgery, THEN 5000 units SC 4-8 hr postsurgery, THEREAFTER 5000 units SC qDay
Deep vein thrombosis prophylaxis for abdominal surgery
2500 IU SC 1-2 hr preop, THEREAFTER 2500 units SC qDay
High risk of thromboembolic complications (eg, malignancy): 5000 units SC evening before surgery, THEN 5000 units qDay (first dose may be evenly split in a preop & postop dose)
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Contraindicated (3)
- defibrotide
defibrotide increases effects of dalteparin by pharmacodynamic synergism. Contraindicated. Coadministration of defibrotide is contraindicated with antithrombotic/fibrinolytic drugs. This does not include use for routine maintenance or reopening of central venous lines.
- mifepristone
mifepristone, dalteparin. Other (see comment). Contraindicated. Comment: Mifepristone may lead to excessive post abortion bleeding in pts. on anticoagulant therapy.
- prothrombin complex concentrate, human
dalteparin, prothrombin complex concentrate, human. pharmacodynamic antagonism. Contraindicated.
Serious - Use Alternative (69)
- abciximab
dalteparin, abciximab. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.
- amobarbital
amobarbital decreases effects of dalteparin by increasing metabolism. Avoid or Use Alternate Drug.
- anagrelide
dalteparin, anagrelide. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.
- antithrombin alfa
antithrombin alfa and dalteparin both increase anticoagulation. Avoid or Use Alternate Drug.
- antithrombin III
antithrombin III and dalteparin both increase anticoagulation. Avoid or Use Alternate Drug.
- apixaban
dalteparin and apixaban both increase anticoagulation. Avoid or Use Alternate Drug.
- argatroban
argatroban and dalteparin both increase anticoagulation. Avoid or Use Alternate Drug.
- azithromycin
azithromycin increases effects of dalteparin by decreasing metabolism. Avoid or Use Alternate Drug.
- bazedoxifene/conjugated estrogens
bazedoxifene/conjugated estrogens decreases effects of dalteparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.
- bemiparin
bemiparin and dalteparin both increase anticoagulation. Avoid or Use Alternate Drug.
- bivalirudin
bivalirudin and dalteparin both increase anticoagulation. Avoid or Use Alternate Drug.
- butabarbital
butabarbital decreases effects of dalteparin by increasing metabolism. Avoid or Use Alternate Drug.
- butalbital
butalbital decreases effects of dalteparin by increasing metabolism. Avoid or Use Alternate Drug.
- caplacizumab
caplacizumab, dalteparin. Either increases effects of the other by anticoagulation. Avoid or Use Alternate Drug.
- cefamandole
cefamandole increases effects of dalteparin by pharmacodynamic synergism. Avoid or Use Alternate Drug.
- cefazolin
cefazolin increases effects of dalteparin by pharmacodynamic synergism. Avoid or Use Alternate Drug.
- cefdinir
cefdinir increases effects of dalteparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity.
- cefditoren
cefditoren will increase the level or effect of dalteparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity
- cefotetan
cefotetan increases effects of dalteparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity.
- cefoxitin
cefoxitin will increase the level or effect of dalteparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity
- cefpodoxime
cefpodoxime will increase the level or effect of dalteparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity
- ceftriaxone
ceftriaxone increases effects of dalteparin by anticoagulation. Avoid or Use Alternate Drug. Cephalosporins may decrease prothrombin activity.
- cefuroxime
cefuroxime will increase the level or effect of dalteparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity
- cilostazol
dalteparin, cilostazol. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.
- clarithromycin
clarithromycin increases effects of dalteparin by decreasing metabolism. Avoid or Use Alternate Drug.
- clopidogrel
dalteparin, clopidogrel. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.
- conjugated estrogens
conjugated estrogens decreases effects of dalteparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.
- dabigatran
dabigatran and dalteparin both increase anticoagulation. Avoid or Use Alternate Drug. Both drugs have the potential to cause bleeding. Concomitant use may increase risk of bleeding.
- dipyridamole
dalteparin, dipyridamole. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.
- edoxaban
edoxaban, dalteparin. Either increases toxicity of the other by anticoagulation. Avoid or Use Alternate Drug. Both drugs have the potential to cause bleeding, monitor closely. Promptly evaluate any signs or symptoms of blood loss. Long-term concomitant treatment with edoxaban and other anticoagulants is not recommended. Short-term coadministration may be needed for patients transitioning to or from edoxaban.
- enoxaparin
dalteparin and enoxaparin both increase anticoagulation. Avoid or Use Alternate Drug.
- eptifibatide
dalteparin, eptifibatide. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.
- erythromycin base
erythromycin base increases effects of dalteparin by decreasing metabolism. Avoid or Use Alternate Drug.
- erythromycin ethylsuccinate
erythromycin ethylsuccinate increases effects of dalteparin by decreasing metabolism. Avoid or Use Alternate Drug.
- erythromycin lactobionate
erythromycin lactobionate increases effects of dalteparin by decreasing metabolism. Avoid or Use Alternate Drug.
- erythromycin stearate
erythromycin stearate increases effects of dalteparin by decreasing metabolism. Avoid or Use Alternate Drug.
- estradiol
estradiol decreases effects of dalteparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.
- estrogens conjugated synthetic
estrogens conjugated synthetic decreases effects of dalteparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.
- estropipate
estropipate decreases effects of dalteparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.
- Factor X, human
dalteparin will decrease the level or effect of Factor X, human by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Based on the mechanism of action, Factor X is likely to be counteracted by direct and indirect Factor Xa inhibitors.
- fondaparinux
dalteparin and fondaparinux both increase anticoagulation. Avoid or Use Alternate Drug.
- heparin
dalteparin and heparin both increase anticoagulation. Avoid or Use Alternate Drug.
- levonorgestrel intrauterine
levonorgestrel intrauterine, dalteparin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- levonorgestrel oral
levonorgestrel oral, dalteparin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- liothyronine
liothyronine increases effects of dalteparin by pharmacodynamic synergism. Avoid or Use Alternate Drug.
- mestranol
mestranol decreases effects of dalteparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.
- moexipril
dalteparin increases toxicity of moexipril by Other (see comment). Avoid or Use Alternate Drug. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- pentobarbital
pentobarbital decreases effects of dalteparin by increasing metabolism. Avoid or Use Alternate Drug.
- perindopril
dalteparin increases toxicity of perindopril by Other (see comment). Avoid or Use Alternate Drug. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- phenindione
dalteparin and phenindione both increase anticoagulation. Avoid or Use Alternate Drug.
- phenobarbital
phenobarbital decreases effects of dalteparin by increasing metabolism. Avoid or Use Alternate Drug.
- piperacillin
piperacillin increases effects of dalteparin by anticoagulation. Avoid or Use Alternate Drug. Piperacillin can inhibit platelet aggregation.
- primidone
primidone decreases effects of dalteparin by increasing metabolism. Avoid or Use Alternate Drug.
- protamine
dalteparin and protamine both increase anticoagulation. Avoid or Use Alternate Drug.
- quinapril
dalteparin increases toxicity of quinapril by Other (see comment). Avoid or Use Alternate Drug. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- quinine
quinine increases effects of dalteparin by unknown mechanism. Avoid or Use Alternate Drug.
- ramipril
dalteparin increases toxicity of ramipril by Other (see comment). Avoid or Use Alternate Drug. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- roxithromycin
roxithromycin increases effects of dalteparin by decreasing metabolism. Avoid or Use Alternate Drug.
- secobarbital
secobarbital decreases effects of dalteparin by increasing metabolism. Avoid or Use Alternate Drug.
- sulfadiazine
sulfadiazine increases effects of dalteparin by decreasing metabolism. Avoid or Use Alternate Drug.
sulfadiazine increases effects of dalteparin by plasma protein binding competition. Avoid or Use Alternate Drug. - sulfamethoxazole
sulfamethoxazole increases effects of dalteparin by decreasing metabolism. Avoid or Use Alternate Drug.
sulfamethoxazole increases effects of dalteparin by plasma protein binding competition. Avoid or Use Alternate Drug. - sulfisoxazole
sulfisoxazole increases effects of dalteparin by decreasing metabolism. Avoid or Use Alternate Drug.
sulfisoxazole increases effects of dalteparin by plasma protein binding competition. Avoid or Use Alternate Drug. - thyroid desiccated
thyroid desiccated increases effects of dalteparin by pharmacodynamic synergism. Avoid or Use Alternate Drug.
- tibolone
tibolone increases effects of dalteparin by pharmacodynamic synergism. Avoid or Use Alternate Drug.
- ticlopidine
dalteparin, ticlopidine. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.
- tirofiban
dalteparin, tirofiban. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.
- trandolapril
dalteparin increases toxicity of trandolapril by Other (see comment). Avoid or Use Alternate Drug. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- vortioxetine
vortioxetine and dalteparin both increase anticoagulation. Avoid or Use Alternate Drug.
- zanubrutinib
dalteparin, zanubrutinib. Either increases effects of the other by anticoagulation. Avoid or Use Alternate Drug.
Monitor Closely (135)
- acalabrutinib
acalabrutinib increases effects of dalteparin by anticoagulation. Use Caution/Monitor. Coadministration of acalabrutinib with antiplatelets or anticoagulants may further increase risk of hemorrhage. Monitor for signs of bleeding and consider the benefit-risk of withholding acalabrutinib for 3-7 days presurgery and postsurgery depending upon the type of surgery and the risk of bleeding.
- aceclofenac
dalteparin and aceclofenac both increase anticoagulation. Modify Therapy/Monitor Closely.
- acemetacin
dalteparin and acemetacin both increase anticoagulation. Modify Therapy/Monitor Closely.
- agrimony
dalteparin and agrimony both increase anticoagulation. Modify Therapy/Monitor Closely.
- alfalfa
dalteparin and alfalfa both increase anticoagulation. Modify Therapy/Monitor Closely.
- alteplase
dalteparin and alteplase both increase anticoagulation. Modify Therapy/Monitor Closely.
- American ginseng
dalteparin and American ginseng both increase anticoagulation. Modify Therapy/Monitor Closely.
- amiloride
amiloride, dalteparin. Either increases toxicity of the other by serum potassium. Use Caution/Monitor. Both drugs may increase serum potassium levels.
- anamu
dalteparin and anamu both increase anticoagulation. Use Caution/Monitor.
- aspirin
dalteparin and aspirin both increase anticoagulation. Modify Therapy/Monitor Closely.
aspirin, dalteparin. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. The need for simultaneous use of low-dose aspirin and anticoagulant or antiplatelet agents are common for patients with cardiovascular disease; monitor closely. - aspirin rectal
dalteparin and aspirin rectal both increase anticoagulation. Modify Therapy/Monitor Closely.
- aspirin/citric acid/sodium bicarbonate
aspirin/citric acid/sodium bicarbonate, dalteparin. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. The need for simultaneous use of low-dose aspirin and anticoagulant or antiplatelet agents are common for patients with cardiovascular disease; monitor closely.
dalteparin and aspirin/citric acid/sodium bicarbonate both increase anticoagulation. Modify Therapy/Monitor Closely. - azapropazone
azapropazone increases effects of dalteparin by plasma protein binding competition. Use Caution/Monitor.
- azathioprine
azathioprine decreases effects of dalteparin by unknown mechanism. Use Caution/Monitor.
- azficel-T
azficel-T, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Coadministration with anticoagulants or antiplatelets may increase bruising or bleeding at biopsy and/or injection sites; concomitant use not recommended. Decisions regarding continued use or cessation of anticoagulants or antiplatelets should be made by a physician.
- azilsartan
dalteparin increases toxicity of azilsartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- benazepril
dalteparin increases toxicity of benazepril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- betrixaban
dalteparin, betrixaban. Either increases levels of the other by anticoagulation. Use Caution/Monitor.
- budesonide
budesonide, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.
- candesartan
dalteparin increases toxicity of candesartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- capecitabine
capecitabine increases effects of dalteparin by unspecified interaction mechanism. Use Caution/Monitor.
- captopril
dalteparin increases toxicity of captopril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- carbamazepine
carbamazepine decreases levels of dalteparin by increasing metabolism. Use Caution/Monitor.
- celecoxib
dalteparin and celecoxib both increase anticoagulation. Modify Therapy/Monitor Closely.
- chitosan
chitosan increases effects of dalteparin by Other (see comment). Use Caution/Monitor. Comment: Chitosan can decrease GI absorption of vitamin K, enhancing anticoagulant effects.
- choline magnesium trisalicylate
dalteparin and choline magnesium trisalicylate both increase anticoagulation. Modify Therapy/Monitor Closely.
- cinnamon
dalteparin and cinnamon both increase anticoagulation. Modify Therapy/Monitor Closely.
- citalopram
citalopram increases effects of dalteparin by pharmacodynamic synergism. Use Caution/Monitor. Combination may increase risk of bleeding.
- collagenase clostridium histolyticum
dalteparin increases toxicity of collagenase clostridium histolyticum by anticoagulation. Use Caution/Monitor. Collagenase clostridium histolyticum has high incidence of ecchymosis/contusion at injection site; avoid concomitant anticoagulants (except for low-dose aspirin, ie, up to 150 mg/day).
- conjugated estrogens, vaginal
conjugated estrogens, vaginal decreases effects of dalteparin by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Risk of thromboembolic disorders.
- cordyceps
dalteparin and cordyceps both increase anticoagulation. Modify Therapy/Monitor Closely.
- cornsilk
cornsilk decreases effects of dalteparin by pharmacodynamic antagonism. Use Caution/Monitor. Cornsilk contains vitamin K; consume a consistent amount daily.
- cortisone
cortisone, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.
- cyclophosphamide
cyclophosphamide increases effects of dalteparin by unknown mechanism. Use Caution/Monitor. Due to potential thrombocytopenic effects of cyclophosphamide, an additive risk of bleeding may be seen in patients receiving concomitant anticoagulants.
- danshen
dalteparin and danshen both increase anticoagulation. Use Caution/Monitor.
- deferasirox
deferasirox, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Gastric ulceration and GI bleeding have been reported in patients taking deferasirox, use caution when coadministering with other drugs known to increase the risk of peptic ulcers or gastric hemorrhage including anticoagulants.
- deflazacort
deflazacort, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.
- devil's claw
dalteparin and devil's claw both increase anticoagulation. Use Caution/Monitor.
- dexamethasone
dexamethasone, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.
- diclofenac
dalteparin and diclofenac both increase anticoagulation. Modify Therapy/Monitor Closely.
- diflunisal
dalteparin and diflunisal both increase anticoagulation. Modify Therapy/Monitor Closely.
diflunisal increases effects of dalteparin by plasma protein binding competition. Use Caution/Monitor. - dong quai
dalteparin and dong quai both increase anticoagulation. Modify Therapy/Monitor Closely.
- enalapril
dalteparin increases toxicity of enalapril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- epoprostenol
dalteparin and epoprostenol both increase anticoagulation. Modify Therapy/Monitor Closely.
- eprosartan
dalteparin increases toxicity of eprosartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- ethanol
ethanol increases effects of dalteparin by unknown mechanism. Use Caution/Monitor. Acute EtOH intoxication.
- ethotoin
dalteparin increases levels of ethotoin by unknown mechanism. Use Caution/Monitor.
ethotoin, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Hydantoin anticonvulsants increase anticoagulant effects at first, then decrease those effects with continued use (2+ wks). There are multiple mechanisms involved, including enzyme induction, plasma protein binding site competition, and additive effects on prothrombin time. - etodolac
dalteparin and etodolac both increase anticoagulation. Modify Therapy/Monitor Closely.
- fenbufen
dalteparin and fenbufen both increase anticoagulation. Modify Therapy/Monitor Closely.
- fennel
dalteparin and fennel both increase anticoagulation. Modify Therapy/Monitor Closely.
- fenoprofen
dalteparin and fenoprofen both increase anticoagulation. Modify Therapy/Monitor Closely.
- feverfew
dalteparin and feverfew both increase anticoagulation. Modify Therapy/Monitor Closely.
- fish oil
fish oil, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Patients taking fish oil and an anticoagulant or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding. .
- fish oil triglycerides
fish oil triglycerides will increase the level or effect of dalteparin by anticoagulation. Use Caution/Monitor. Prolonged bleeding reported in patients taking antiplatelet agents or anticoagulants and oral omega-3 fatty acids. Periodically monitor bleeding time in patients receiving fish oil triglycerides and concomitant antiplatelet agents or anticoagulants.
- fludrocortisone
fludrocortisone, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.
- fluorouracil
fluorouracil increases effects of dalteparin by unspecified interaction mechanism. Use Caution/Monitor. Due to the thrombocytopenic effects of fluorouracil, an additive risk of bleeding may be seen in patients receiving concomitant anticoagulants.
- flurbiprofen
dalteparin and flurbiprofen both increase anticoagulation. Modify Therapy/Monitor Closely.
- forskolin
dalteparin and forskolin both increase anticoagulation. Modify Therapy/Monitor Closely.
- fosinopril
dalteparin increases toxicity of fosinopril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- fosphenytoin
dalteparin increases levels of fosphenytoin by unknown mechanism. Use Caution/Monitor.
fosphenytoin, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Hydantoin anticonvulsants increase anticoagulant effects at first, then decrease those effects with continued use (2+ wks). There are multiple mechanisms involved, including enzyme induction, plasma protein binding site competition, and additive effects on prothrombin time. - garlic
dalteparin and garlic both increase anticoagulation. Modify Therapy/Monitor Closely.
- gemcitabine
gemcitabine increases effects of dalteparin by unspecified interaction mechanism. Use Caution/Monitor. Due to the thrombocytopenic effects of gemcitabine, an additive risk of bleeding may be seen in patients receiving concomitant anticoagulants.
- ginger
dalteparin and ginger both increase anticoagulation. Modify Therapy/Monitor Closely.
- ginkgo biloba
dalteparin and ginkgo biloba both increase anticoagulation. Modify Therapy/Monitor Closely.
- glucagon intranasal
glucagon intranasal increases effects of dalteparin by unknown mechanism. Use Caution/Monitor.
- green tea
green tea, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Combination may increase risk of bleeding, caution is advised.
- hemin
dalteparin, hemin. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Hemin degradation product (ie, hematin) may produce coagulopathy (eg, thrombocytopenia, platelet degranulation) and cause mild anticoagulant effects.
- horse chestnut seed
dalteparin and horse chestnut seed both increase anticoagulation. Modify Therapy/Monitor Closely.
- hydrocortisone
hydrocortisone, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.
- ibrutinib
ibrutinib will increase the level or effect of dalteparin by anticoagulation. Use Caution/Monitor. Ibrutinib may increase the risk of hemorrhage in patients receiving antiplatelet or anticoagulant therapies and monitor for signs of bleeding.
- ibuprofen
dalteparin and ibuprofen both increase anticoagulation. Modify Therapy/Monitor Closely.
- ibuprofen IV
dalteparin and ibuprofen IV both increase anticoagulation. Modify Therapy/Monitor Closely.
- icosapent
icosapent, dalteparin. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Icosapent may prolong bleeding time; monitor periodically if coadministered with other drugs that affect bleeding.
- imatinib
imatinib, dalteparin. Either increases toxicity of the other by Other (see comment). Modify Therapy/Monitor Closely. Comment: Imatinib may cause thrombocytopenia; bleeding risk increased when imatinib is coadministered with anticoagulants, NSAIDs, platelet inhibitors, and thrombolytic agents; patients requiring anticoagulation while on imatinib should receive LMWH or unfractionated heparin instead of warfarin because of multiple interaction mechanisms of imatinib with warfarin.
- indomethacin
dalteparin and indomethacin both increase anticoagulation. Modify Therapy/Monitor Closely.
- iodine (radioactive)
iodine (radioactive) decreases effects of dalteparin by pharmacodynamic antagonism. Use Caution/Monitor.
- irbesartan
dalteparin increases toxicity of irbesartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- ketoprofen
dalteparin and ketoprofen both increase anticoagulation. Modify Therapy/Monitor Closely.
- ketorolac
dalteparin and ketorolac both increase anticoagulation. Modify Therapy/Monitor Closely.
- ketorolac intranasal
dalteparin and ketorolac intranasal both increase anticoagulation. Modify Therapy/Monitor Closely.
- lisinopril
dalteparin increases toxicity of lisinopril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- lofepramine
lofepramine increases levels of dalteparin by decreasing metabolism. Use Caution/Monitor.
- lornoxicam
dalteparin and lornoxicam both increase anticoagulation. Modify Therapy/Monitor Closely.
- losartan
dalteparin increases toxicity of losartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- meclofenamate
dalteparin and meclofenamate both increase anticoagulation. Modify Therapy/Monitor Closely.
- mefenamic acid
dalteparin and mefenamic acid both increase anticoagulation. Modify Therapy/Monitor Closely.
- melatonin
melatonin increases effects of dalteparin by anticoagulation. Use Caution/Monitor. Melatonin may decrease prothrombin time.
- meloxicam
dalteparin and meloxicam both increase anticoagulation. Modify Therapy/Monitor Closely.
- methimazole
methimazole decreases effects of dalteparin by pharmacodynamic antagonism. Use Caution/Monitor.
- methylprednisolone
methylprednisolone, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.
- mistletoe
dalteparin increases and mistletoe decreases anticoagulation. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.
- nabumetone
dalteparin and nabumetone both increase anticoagulation. Modify Therapy/Monitor Closely.
- naproxen
dalteparin and naproxen both increase anticoagulation. Modify Therapy/Monitor Closely.
- nettle
dalteparin increases and nettle decreases anticoagulation. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.
- nintedanib
nintedanib increases effects of dalteparin by anticoagulation. Use Caution/Monitor. Nintedanib is a VEGFR inhibitor, and may increase the risk of bleeding; monitor patients on full anticoagulation therapy; monitor closely for bleeding and adjust therapy as needed .
- olmesartan
dalteparin increases toxicity of olmesartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- omega 3 carboxylic acids
omega 3 carboxylic acids, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Patients taking omega-3 acids and an anticoagulant or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding.
- omega 3 fatty acids
omega 3 fatty acids, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Patients taking omega-3-fatty acids and an anticoagulant or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding. .
- oxaprozin
dalteparin and oxaprozin both increase anticoagulation. Modify Therapy/Monitor Closely.
- panax ginseng
dalteparin and panax ginseng both increase anticoagulation. Modify Therapy/Monitor Closely.
- parecoxib
dalteparin and parecoxib both increase anticoagulation. Modify Therapy/Monitor Closely.
- pau d'arco
dalteparin and pau d'arco both increase anticoagulation. Modify Therapy/Monitor Closely.
- pegaspargase
pegaspargase increases effects of dalteparin by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of bleeding events.
- phenytoin
dalteparin increases levels of phenytoin by unknown mechanism. Use Caution/Monitor.
phenytoin, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Hydantoin anticonvulsants increase anticoagulant effects at first, then decrease those effects with continued use (2+ wks). There are multiple mechanisms involved, including enzyme induction, plasma protein binding site competition, and additive effects on prothrombin time. - phytoestrogens
dalteparin and phytoestrogens both increase anticoagulation. Modify Therapy/Monitor Closely.
- piroxicam
dalteparin and piroxicam both increase anticoagulation. Modify Therapy/Monitor Closely.
- porfimer
dalteparin decreases effects of porfimer by pharmacodynamic antagonism. Use Caution/Monitor.
- prasugrel
dalteparin, prasugrel. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Enhanced risk of hemorrhage.
- prednisolone
prednisolone, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.
- prednisone
prednisone, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.
- propafenone
propafenone increases effects of dalteparin by decreasing metabolism. Use Caution/Monitor.
- propylthiouracil
propylthiouracil decreases effects of dalteparin by pharmacodynamic antagonism. Use Caution/Monitor.
- reishi
dalteparin and reishi both increase anticoagulation. Modify Therapy/Monitor Closely.
- reteplase
dalteparin and reteplase both increase anticoagulation. Modify Therapy/Monitor Closely.
- rifabutin
rifabutin decreases levels of dalteparin by increasing metabolism. Use Caution/Monitor.
- rivaroxaban
rivaroxaban, dalteparin. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Avoid concurrent use of rivaroxaban with other anticoagulants due to increased bleeding risk other than during therapeutic transition periods where patients should be observed closely. Monitor for signs/symptoms of blood loss.
- sacubitril/valsartan
dalteparin increases toxicity of sacubitril/valsartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- salicylates (non-asa)
dalteparin and salicylates (non-asa) both increase anticoagulation. Modify Therapy/Monitor Closely.
- salsalate
dalteparin and salsalate both increase anticoagulation. Modify Therapy/Monitor Closely.
- saw palmetto
saw palmetto increases toxicity of dalteparin by unspecified interaction mechanism. Use Caution/Monitor. May increase risk of bleeding.
- Siberian ginseng
dalteparin and Siberian ginseng both increase anticoagulation. Modify Therapy/Monitor Closely.
- spironolactone
spironolactone, dalteparin. Either increases toxicity of the other by serum potassium. Use Caution/Monitor. Both drugs may increase serum potassium levels.
- sulfasalazine
dalteparin and sulfasalazine both increase anticoagulation. Modify Therapy/Monitor Closely.
- sulindac
dalteparin and sulindac both increase anticoagulation. Modify Therapy/Monitor Closely.
- telmisartan
dalteparin increases toxicity of telmisartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- tenecteplase
dalteparin and tenecteplase both increase anticoagulation. Modify Therapy/Monitor Closely.
- ticagrelor
ticagrelor, dalteparin. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Increased risk of bleeding during concomitant use of medications that increase potential for bleeding.
- tipranavir
tipranavir increases effects of dalteparin by pharmacodynamic synergism. Use Caution/Monitor. Tipranavir has mild antiplatelet activity that may incr bleeding risk.
- tolfenamic acid
dalteparin and tolfenamic acid both increase anticoagulation. Modify Therapy/Monitor Closely.
- tolmetin
dalteparin and tolmetin both increase anticoagulation. Modify Therapy/Monitor Closely.
- triamcinolone acetonide injectable suspension
triamcinolone acetonide injectable suspension, dalteparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.
- triamterene
triamterene, dalteparin. Either increases toxicity of the other by serum potassium. Use Caution/Monitor. Both drugs may increase serum potassium levels.
- triclofos
triclofos increases effects of dalteparin by unspecified interaction mechanism. Use Caution/Monitor.
- valsartan
dalteparin increases toxicity of valsartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.
- vorapaxar
dalteparin, vorapaxar. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Coadministration of anticoagulants, antiplatelets, or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding.
Minor (18)
- acetaminophen
acetaminophen increases effects of dalteparin by unknown mechanism. Minor/Significance Unknown.
- acetaminophen IV
acetaminophen IV increases effects of dalteparin by unknown mechanism. Minor/Significance Unknown.
- acetaminophen rectal
acetaminophen rectal increases effects of dalteparin by unknown mechanism. Minor/Significance Unknown.
- alprostadil intracavernous/urethral
alprostadil intracavernous/urethral increases effects of dalteparin by pharmacodynamic synergism. Minor/Significance Unknown.
- ceftaroline
ceftaroline increases effects of dalteparin by Other (see comment). Minor/Significance Unknown. Comment: Cephalosporins with a methylthiotetrazole (MTT) side ring (eg, cefotetan, cefoperazone) are more frequently associated with hypoprothrombinemic activity.
- chlorella
chlorella decreases effects of dalteparin by pharmacodynamic antagonism. Minor/Significance Unknown. Theoretical, due to vitamin K content.
- demeclocycline
demeclocycline increases effects of dalteparin by pharmacodynamic synergism. Minor/Significance Unknown.
- dexmethylphenidate
dexmethylphenidate increases effects of dalteparin by decreasing metabolism. Minor/Significance Unknown.
- doxycycline
doxycycline increases effects of dalteparin by pharmacodynamic synergism. Minor/Significance Unknown.
- glyburide
glyburide increases effects of dalteparin by unspecified interaction mechanism. Minor/Significance Unknown.
- mineral oil
mineral oil decreases levels of dalteparin by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.
- minocycline
minocycline increases effects of dalteparin by pharmacodynamic synergism. Minor/Significance Unknown.
- oxytetracycline
oxytetracycline increases effects of dalteparin by pharmacodynamic synergism. Minor/Significance Unknown.
- quinidine
quinidine increases effects of dalteparin by decreasing metabolism. Minor/Significance Unknown.
- serdexmethylphenidate/dexmethylphenidate
serdexmethylphenidate/dexmethylphenidate increases effects of dalteparin by decreasing metabolism. Minor/Significance Unknown.
- tetracycline
tetracycline increases effects of dalteparin by pharmacodynamic synergism. Minor/Significance Unknown.
- verteporfin
dalteparin decreases effects of verteporfin by pharmacodynamic antagonism. Minor/Significance Unknown.
- vitamin E
vitamin E, dalteparin. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Vitamin E at RDA does not change INR in pts. on chronic warfarin therapy; megadoses (~10x RDA) may enhance anticoagulant effects in vitamin K deficient pts.
Adverse Effects
1-10%
Injection site hematoma (7-35%)
Thrombocytopenia (10.9-13.6%, patients with cancer )
Injection site pain (4.5-12%)
Major hemorrhage (up to 4.6%)
Increased liver function test (up to 4.3%)
Wound hematoma
Hematuria
Frequency Not Defined
Epidural hematoma
Spinal hematoma
Hemorrhagic cerebral infarction
Intracranial hemorrhage
Intrauterine subdural hemorrhage
Thrombocytopenia (<1%, non-cancer indications)
Anaphylactoid reaction (rare)
Postmarketing Reports
Osteoporosis
Skin necrosis
Alopecia
Warnings
Black Box Warnings
Epidural or spinal hematomas may occur in patients anticoagulated with LMWH or heparinoids who receive neuraxial (epidural/spinal) anesthesia or spinal puncture
These hematomas may result in long-term or permanent paralysis
Patients should be frequently monitored for signs and symptoms of neurologic impairment; if neurological compromise noted, urgent treatment necessary
Optimal timing between the administration of dalteparin and neuraxial procedures is not known
Physicians should consider the benefits versus risk before neuraxial intervention in patients anticoagulated or to be anticoagulated for thromboprophylaxis
Factors increasing risk of epidural or spinal hematomas
- Indwelling epidural catheters
- Concomitant use of other drugs that affect hemostasis (eg, NSAIDs, platelet inhibitors, other anticoagulants)
- History of traumatic or repeated epidural or spinal punctures
- History of spinal deformity or spinal surgery
Contraindications
Hypersensitivity to dalteparin, heparin or pork products
Active major bleeding, thrombocytopenia associated with antiplatelet antibodies
History of heparin-induced thrombocytopenia or heparin-induced thrombocytopenia with thrombosis
Patients undergoing epidural/neuraxial anesthesia, as a treatment for unstable angina and non-Q-wave MI or for prolonged VTE prophylaxis
Cautions
Risk of epidural/spinal hematoma if used in patients getting epidural/spinal anesthesia which may result in paralysis
Periodic routine complete blood cell counts, including platelet count, blood chemistry, and stool occult blood tests are recommended during treatment
Use caution in patients with history of heparin-induced thrombocytopenia; heparin-induced thrombocytopenia can occur with administration of this drug; the incidence of this complication is unknown at present; in clinical practice, cases of thrombocytopenia with thrombosis, amputation and death have been observed; closely monitor thrombocytopenia of any degree
Do not give IM
Can't be used interchangeably with other LMW heparins
Multidose vials contain benzyl alcohol as preservative (associated with potentially fatal "Gasping Syndrome" in preemies); when prescribing dalteparin multiple-dose vials in neonates and low-birth-weight infants, consider combined daily metabolic load of benzyl alcohol from all sources including multiple-dose vials (dalteparin contains 14 mg of benzyl alcohol per mL) and other drugs containing benzyl alcohol; minimum amount of benzyl alcohol at which serious adverse reactions may occur not known
If signs or symptoms of spinal hematoma are suspected, initiate urgent diagnosis and treatment including consideration for spinal cord decompression even though such treatment may not prevent or reverse neurological sequelae
Although specific recommendation for timing of a subsequent dose after catheter removal is unknown, consider delaying this next dose for at least four hours, based on a benefit-risk assessment considering both the risk for thrombosis and the risk for bleeding in the context of the procedure and patient risk factors
Risk of hemorrhage
- Spinal or epidural hemorrhage and subsequent hematomas can occur with associated use of low molecular weight heparins or heparinoids and neuraxial (spinal/epidural) anesthesia or spinal puncture; the risk of these events is higher with use of post-operative indwelling epidural catheters, with concomitant use of additional drugs affecting hemostasis such as NSAIDs, with traumatic or repeated epidural or spinal puncture, or in patients with a history of spinal surgery or spinal deformity
- To reduce potential risk of bleeding associated with concurrent use of this drug and epidural or spinal anesthesia/analgesia or spinal puncture, consider pharmacokinetic profile of this drug
- Placement or removal of an epidural catheter or lumbar puncture is best performed when anticoagulant effect of this drug is low; however, the exact timing to reach a sufficiently low anticoagulant effect in each patient is not known; no additional hemostasis-altering medications should be administered due to the additive effects
- Patients on preoperative thromboprophylaxis can be assumed to have altered coagulation; the first postoperative-thromboprophylaxis dose (2,500 IU) should be administered 6-8 hours postoperatively; the second postoperative dose(2,500 or 5,000 IU) should occur no sooner than 24 hr after first dose
- Placement or removal of a catheter should be delayed for at least 12 hours after administration of 2,500 IU once daily, at least 15 hours after administration of 5,000 IU once daily of FRAGMIN, and at least 24 hours after administration of higher doses (200 IU/kg once daily, 120 IU/kg twice daily); anti-Xa levels are still detectable at these time points, and these delays are not a guarantee that neuraxial hematoma will be avoided
- Although a specific recommendation for timing of subsequent dose after catheter removal cannot be made, consider delaying next dose for at least 4 hr, based on benefit-risk assessment considering both risk for thrombosis and risk for bleeding in context of procedure and patient risk factors
- For patients with creatinine clearance <30mL/minute, additional considerations are necessary because elimination of this drug may be more prolonged; consider doubling timing of removal of catheter, at least 24 hr for lower prescribed dose (2,500 IU or 5,000 IU once daily) and at least 48 hours for higher dose (200 IU/kg once daily, 120 IU/kg twice daily)
- Should the physician decide to administer anticoagulation in context of epidural or spinal anesthesia/analgesia or lumbar puncture, frequent monitoring must be exercised to detect signs and symptoms of neurological impairment such as midline back pain, sensory and motor deficits (numbness or weakness in lower limbs), bowel and/or bladder dysfunction
- Instruct patients to report immediately if experience any of above signs or symptoms; if signs or symptoms of spinal hematoma are suspected, initiate urgent diagnosis and treatment including consideration for spinal cord decompression even though such treatment may not prevent or reverse neurological sequelae
- Use this drug with extreme caution in patients who have an increased risk of hemorrhage, such as those with severe uncontrolled hypertension, bacterial endocarditis, congenital or acquired bleeding disorders, active ulceration, and angiodysplastic gastrointestinal disease, hemorrhagic stroke, or shortly after brain, spinal or ophthalmological surgery
- This drug may enhance risk of bleeding in patients with thrombocytopenia or platelet defects; severe liver or kidney insufficiency, hypertensive or diabetic retinopathy, and recent gastrointestinal bleeding; bleeding can occur at any site during therapy
Pregnancy & Lactation
Pregnancy
Available data have not reported a clear association with dalteparin and adverse developmental outcomes
There are risks to the mother associated with untreated VTE in pregnancy, and a potential for adverse effects on the preterm infant when used in pregnancy
Animal data
- In animal reproduction studies, there was no evidence of embryofetal toxicity or teratogenicity when dalteparin sodium was administered to pregnant rats and rabbits during organogenesis at doses 2-4 times (rats) and 4 times (rabbits) the human dose of 100 IU/kg dalteparin based on the BSA
- Since animal studies are not always indicative of human response, use during pregnancy only if clearly needed
Clinical considerations
- Published data describe that women with a previous history of VTE in pregnancy are at higher risk for recurrence during subsequent pregnancies compared to those with no risk factor for VTE
- Cases of “gasping syndrome” have occurred in premature infants when large amounts of benzyl alcohol have been administered (99-404 mg/kg/day)
- Multiple-dose 3.8 mL vials of dalteparin contain 14 mg/mL of benzyl alcohol
Lactation
Limited published data indicate that the drug is present in human milk in small amounts; no adverse effects on breastfed infant reported; there are no data on effects of drug on milk production; oral absorption of dalteparin is expected to be low, but clinical implications, if any, of this small amount of anticoagulant activity on a breastfed infant are unknown; developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and any potential adverse effects on breastfed child from the drug or from underlying maternal condition
Pregnancy Categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available.Pharmacology
Mechanism of Action
LMW heparin with antithrombotic properties; enhances inhibition of Factor Xa & thrombin by antithrombin, minimal effect on APTT
Absorption
Adults
- Peak plasma anti-Xa activity: 0.19 IU/mL (2500 IU-dose), 0.41 IU/mL (5000 IU-dose), and 0.82 IU/mL (10,000 IU-dose)
- Absolute bioavailability: 87%
Distribution
Adults
- Vd: 40-60 mL/kg
Elimination
Half-life (pediatrics)
- 3 to <8 weeks: 2.25 hr
- ≥8 weeks to <2 years: 3.02 hr
- ≥2 to <8 years: 4.27 hr
- ≥8 to <12 years: 5.11 hr
- ≥12 to <20 years: 6.28 hr
Half-life (adults)
- 2.1 hr (40 IU/kg); 2.3 hr (60 IU/kg); 5.7 hr (single IV 5000 IU-dose)
- Longer apparent terminal half-lives (3-5 hr) are observed following SC dosing, possibly due to delayed absorption
Clearance (pediatrics)
- 3 to <8 weeks: 55.8 mL/hr/kg
- ≥8 weeks to <2 years: 40.4 mL/hr/kg
- ≥2 to <8 years: 26.7 mL/hr/kg
- ≥8 to <12 years: 22.4 mL/hr/kg
- ≥12 to <20 years:18.8 mL/hr/kg
Clearance (adults)
- Clearance: 24.6 mL/hr/kg (30 IU/kg); 15.6 mL/hr/kg (120 IU/kg)
Administration
SC Administration
SC use only; do not be administer IM
Do not be mixed with other injections or infusions unless specific compatibility data supports such mixing
Patients should be sitting or lying down and administered by deep SC injection
Inject in a U-shape area around navel, upper outer side of thigh or upper outer quadrangle of the buttock; injection site should be varied daily
When area around the navel or thigh is used, using the thumb and forefinger, you must lift up a fold of skin while giving the injection
Entire length of the needle should be inserted at a 45-90° angle
Inspect prefilled syringes and vials visually for particulate matter and discoloration prior to administration
Fixed dose syringes: Ensure delivery of the full dose; do not expel the air bubble from prefilled syringe before injection; discard syringe assembly after use
Graduated syringes: Hold syringe assembly by the open sides of the device; with the needle pointing up, expel air bubble(s) and then continue to push plunger to desired dose or volume, discarding extra solution in an appropriate manner; discard the syringe assembly after use
Storage
Opened vials
- After first penetration of the rubber stopper, store multiple-dose vials at room temperature for up to 2 weeks
- Discard any unused solution after 2 weeks
Unopened syringes and vials
- Store at 20-25°C (68-77°F); excursion permitted to 15-30°C (59-86°F)
Images
| BRAND | FORM. | UNIT PRICE | PILL IMAGE |
|---|---|---|---|
| Fragmin subcutaneous - | 10,000 anti-Xa unit/mL solution |  | |
| Fragmin subcutaneous - | 15,000 anti-Xa unit/0.6 mL solution |  | |
| Fragmin subcutaneous - | 5,000 anti-Xa unit/0.2 mL solution |  | |
| Fragmin subcutaneous - | 2,500 anti-Xa unit/0.2 mL solution |  | |
| Fragmin subcutaneous - | 12,500 anti-Xa unit/0.5 mL solution |  | |
| Fragmin subcutaneous - | 18,000 anti-Xa unit/0.72 mL solution |  | |
| Fragmin subcutaneous - | 10,000 anti-Xa unit/mL solution |  | |
| Fragmin subcutaneous - | 7,500 anti-Xa unit/0.3 mL solution |  | |
| Fragmin subcutaneous - | 5,000 anti-Xa unit/0.2 mL solution |  | |
| Fragmin subcutaneous - | 7,500 anti-Xa unit/0.3 mL solution |  | |
| Fragmin subcutaneous - | 18,000 anti-Xa unit/0.72 mL solution |  | |
| Fragmin subcutaneous - | 15,000 anti-Xa unit/0.6 mL solution |  | |
| Fragmin subcutaneous - | 12,500 anti-Xa unit/0.5 mL solution |  | |
| Fragmin subcutaneous - | 2,500 anti-Xa unit/0.2 mL solution |  | |
| Fragmin subcutaneous - | 25,000 anti-Xa unit/mL vial |  |
Copyright © 2010 First DataBank, Inc.
Patient Handout
dalteparin (porcine) subcutaneous
DALTEPARIN - SUBCUTANEOUS INJECTION
(DAL-te-PAR-in)
COMMON BRAND NAME(S): Fragmin
WARNING: People using this medication may bleed near the spinal cord after certain spinal procedures. Bleeding in this area can cause paralysis that lasts a long time or could become permanent. Talk with your doctor about the benefits and risks before any spinal procedure. Your doctor may direct you to stop this medication for a certain amount of time before and after the procedure. Carefully follow your doctor's directions.The risk of bleeding may be higher if you have a deformed spine, or have had spinal procedures/surgery before (such as epidural catheter placement, difficult epidural/spinal puncture), or are taking other drugs that can cause bleeding/bruising (including antiplatelet drugs such as clopidogrel, "blood thinners" such as warfarin/rivaroxaban, nonsteroidal anti-inflammatory drugs-NSAIDs such as ibuprofen). Tell your doctor right away if you notice symptoms such as back pain, leg numbness/tingling/weakness, loss of control of the bowels or bladder (incontinence).
USES: Dalteparin is used to treat and prevent harmful blood clots. Preventing harmful blood clots helps to reduce the risk of a stroke or heart attack. This medication helps keep your blood flowing smoothly by lowering the activity of clotting proteins in the blood. Dalteparin is a type of heparin, and works as an anticoagulant (commonly called a "blood thinner").Conditions that increase your risk of developing blood clots include certain types of surgeries (such as hip replacement or abdominal surgery), long periods of being in one position (immobile), certain types of heart attack, and a certain type of chest pain called unstable angina. For some medical conditions, dalteparin may be used in combination with other "blood thinners."Dalteparin may also be used to treat and prevent clots from coming back in patients with cancer.
HOW TO USE: Read the Patient Information Leaflet if available from your pharmacist before you start using dalteparin and each time you get a refill. If you have any questions, ask your doctor or pharmacist.This medication is given by injection under the skin as directed by your doctor, usually once or twice daily. Do not inject into a muscle. The dosage and length of treatment are based on your medical condition and response to treatment. The dosage may also be based on your weight for some conditions.If you are using this medication at home, learn all preparation and usage instructions from your health care professional and the product package. You should be lying down or sitting when you inject yourself. Before using, check this product visually for particles or discoloration. If either is present, do not use the liquid. This medication should not be mixed with or added to any other medication in the same syringe. Before injecting each dose, clean the injection site with rubbing alcohol. Change the injection site each time to lessen injury under the skin. To minimize bruising, do not rub the injection site after a shot. Learn how to store and discard medical supplies safely.To prevent blood clots due to surgery, your doctor may direct you to start using this medication before or after surgery and continue for several days. Follow your doctor's directions closely.Use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same time(s) each day.
SIDE EFFECTS: See also Warning section.Irritation, bruising, and pain at the injection site may occur. If any of these effects last or get worse, tell your doctor or pharmacist promptly.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.This medication can cause bleeding if its effect on your blood clotting proteins is too much. Tell your doctor right away if you have any serious signs of bleeding, including: unusual pain/swelling/discomfort, unusual or prolonged bleeding, unusual or easy bruising, dark urine, black stools, severe headache, confusion, vision changes, unusual dizziness, fainting, seizures, weakness, numbness.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
PRECAUTIONS: Before using dalteparin, tell your doctor or pharmacist if you are allergic to it; or to heparins or pork products; or if you have any other allergies. This product may contain inactive ingredients (such as latex found in the needle shield), which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: serious active bleeding, artificial heart valves, bleeding or blood disorders (low platelet counts), certain eye problems (hypertensive or diabetic retinopathy), high blood pressure, infection of the heart, kidney disease, liver disease, low platelet counts after previous heparin treatment, certain stomach/intestinal problems (such as active or recent ulcers), stroke, recent spinal procedures or puncture, spine problems (such as spinal deformity), recent eye/brain/spinal cord surgery.Limit alcohol while taking this drug because it may increase the risk of stomach bleeding.Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).To lower the chance of getting cut, bruised, or injured, use caution with sharp objects like razors and nail cutters, and avoid activities such as contact sports.Older adults may be more sensitive to the side effects of this drug, especially bleeding.During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.This medication passes into breast milk. Consult your doctor before breast-feeding.
DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.One product that may interact with this drug is: mifepristone.This medication is sometimes used together with other drugs that have "blood thinning" or anti-platelet effects such as aspirin, clopidogrel, or warfarin. When these combinations are prescribed by your doctor, you will require closer monitoring to minimize your risk of bleeding. Keep all medical and laboratory appointments.Check all prescription and nonprescription medicine labels carefully since many medications contain pain relievers/fever reducers (NSAIDs such as ibuprofen, naproxen, or aspirin) which can increase the risk of bleeding/anti-platelet effect when used with dalteparin. However, if your doctor has directed you to take low-dose aspirin for heart attack or stroke prevention (usually 81-162 milligrams a day), you should continue taking it unless your doctor instructs you otherwise. Ask your doctor or pharmacist for more details.
OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: excessive bleeding and bruising.
NOTES: Do not share this medication with others.Lab and/or medical tests (such as complete blood count, anti-factor Xa blood levels) should be done while you are using this medication. Keep all medical and lab appointments. Consult your doctor for more details.
MISSED DOSE: If you miss a dose, use it as soon as you remember. If it is near the time of the next dose, skip the missed dose. Use your next dose at the regular time. Do not double the dose to catch up.
STORAGE: Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.
MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information about enrolling in MedicAlert, call 1-888-633-4298 (US) or 1-800-668-1507 (Canada).
Information last revised November 2022. Copyright(c) 2023 First Databank, Inc.
IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.
Formulary
Adding plans allows you to compare formulary status to other drugs in the same class.
To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.
Adding plans allows you to:
- View the formulary and any restrictions for each plan.
- Manage and view all your plans together – even plans in different states.
- Compare formulary status to other drugs in the same class.
- Access your plan list on any device – mobile or desktop.
