What dose of Fragmin (dalteparin) is recommended to cover atrial flutter and deep vein thrombosis (DVT)?

From the Guidelines

For atrial flutter with DVT, Fragmin (dalteparin) is typically dosed at 200 IU/kg once daily subcutaneously, with a maximum daily dose of 18,000 IU, as recommended by the most recent guidelines 1. This dosing regimen is supported by the NCCN clinical practice guidelines in oncology, which suggest that dalteparin is effective in preventing recurrent VTE without increasing the risk of bleeding 1. The guidelines also recommend that the dose be adjusted based on the patient's weight, with a maximum daily dose of 18,000 IU. For patients with high bleeding risk, a reduced dose of 100 IU/kg twice daily may be used, although this is not explicitly stated in the guidelines for atrial flutter and DVT, the principle of dose adjustment for bleeding risk is established 1. Treatment should continue for at least 3 months, with the exact duration depending on risk factors and clinical response. Body weight should be measured accurately to calculate the correct dose. For patients with severe renal impairment (creatinine clearance <30 mL/min), dose reduction and anti-Xa monitoring may be necessary, as suggested by the guidelines 1. Regular monitoring of platelet counts is recommended during the first two weeks of therapy to detect heparin-induced thrombocytopenia. Some key points to consider when using Fragmin (dalteparin) for atrial flutter and DVT include:

• The dose should be adjusted based on the patient's weight
• The maximum daily dose should not exceed 18,000 IU
• Patients with severe renal impairment may require dose reduction and anti-Xa monitoring
• Regular monitoring of platelet counts is necessary to detect heparin-induced thrombocytopenia
• The treatment duration should be at least 3 months, with the exact duration depending on risk factors and clinical response. The most recent and highest quality study 1 supports the use of dalteparin for the treatment of VTE in patients with cancer, and its efficacy in preventing recurrent VTE without increasing the risk of bleeding.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Indication Dosing Regimen ... Extended treatment of VTE in adult patients with cancer Month 1: 200 units/kg subcutaneous once daily (2.3) Months 2 to 6: 150 units/kg subcutaneous once daily (2. 3) Treatment of VTE in pediatric patients (see Table 5) (2.4) Age Group Starting Dose Birth (gestational age at least 35 weeks) to less than 2 Years 150 units/kg twice daily 2 Years to less than 8 Years 125 units/kg twice daily 8 Years to less than 17 Years 100 units/kg twice daily

The recommended dose of Fragmin (dalteparin) for deep vein thrombosis (DVT) is:

• For adult patients with cancer: 200 units/kg subcutaneous once daily for the first month, and 150 units/kg subcutaneous once daily for months 2 to 6.
• For pediatric patients: the dose varies by age group, ranging from 150 units/kg twice daily for patients from birth to less than 2 years, to 100 units/kg twice daily for patients from 8 years to less than 17 years.

However, there is no specific dose recommended for atrial flutter in the provided drug label. 2

From the Research

Recommended Dose of Fragmin (Dalteparin)

The recommended dose of Fragmin (dalteparin) for covering atrial flutter and deep vein thrombosis (DVT) is as follows:

• For atrial fibrillation and TEE-guided cardioversion, the dose is 2 x 100 anti-Xa units/kg, with a maximum dosage of 2 x 10,000 anti-Xa units subcutaneously 3
• This dose is administered for a median of 11 days, with a range of 3-41 days 3

Anticoagulation Therapy

Anticoagulation therapy is effective in preventing recurrence of venous thromboembolism and improving survival in patients with DVT or pulmonary embolism 4

• The therapy should be initiated with immediate systemic heparin anticoagulation at dosages sufficient to rapidly prolong the activated partial thromboplastin time into the laboratory-specific therapeutic range 4
• An oral vitamin K antagonist, such as warfarin, should be started within 24 hours after starting heparin, with a starting dose that is the estimated patient-specific daily dose and no loading dose 4

Atrial Flutter and Cardioversion

For patients with atrial flutter, antithrombotic therapy decisions should follow the same risk-based recommendations as for atrial fibrillation 5

• Cardioversion in atrial fibrillation or flutter can cause arterial embolism, and effective anticoagulation clearly reduces the risk 3
• Transesophageal echocardiography (TEE) can be used to guide cardioversion and reduce the anticoagulation period prior to cardioversion 3