Anticoagulants
| Class | Generic (Brand) | Dose by indication | Renal adjust |
|---|---|---|---|
| LMWH | Enoxaparin (Clexane) | Prophylaxis 40 mg SC OD; treatment 1 mg/kg SC BD | Yes: treatment 1 mg/kg SC OD if eGFR < 30 |
| UFH | Heparin | Treatment: IV infusion (weight-based, APTT-titrated); prophylaxis 5,000 units SC BD/TID | No |
| Factor Xa inhibitor | Fondaparinux (Arixtra) | Prophylaxis 2.5 mg SC OD; treatment weight-based | Yes: avoid if eGFR < 30 |
| DOAC | Apixaban (Eliquis) | AF: 5 mg BD (2.5 mg BD if ≥ 2 of: age ≥ 80, ≤ 60 kg, Cr ≥ 133). VTE: 10 mg BD × 7 days → 5 mg BD; extended 2.5 mg BD | Yes: dose adjust |
| DOAC | Rivaroxaban (Xarelto) | AF: 20 mg OD (15 mg if CrCl 15–49). VTE: 15 mg BD × 21 days → 20 mg OD | Yes: avoid if eGFR < 15 |
| DOAC | Dabigatran (Pradaxa) | AF / VTE: 150 mg BD (110 mg BD if age ≥ 80 or bleeding risk). VTE needs ≥ 5 days parenteral lead-in first | Yes: avoid if CrCl < 30 |
Antiplatelets
| Generic (Brand) | Dose | Notes |
|---|---|---|
| Aspirin | 75–100 mg OD (loading 300 mg) | – |
| Clopidogrel (Plavix) | 75 mg OD (loading 300–600 mg) | – |
| Ticagrelor (Brilinta) | 90 mg BD (loading 180 mg); 60 mg BD for long-term secondary prevention | Avoid with strong CYP3A inhibitors; dyspnoea common |
Reversal orientation
Major or life-threatening bleeding and urgent procedures only. Follow local major-bleeding protocol.
| Agent | Reversal |
|---|---|
| Apixaban / rivaroxaban | Life-threatening/uncontrolled bleeding: follow local protocol. 4F-PCC 25–50 units/kg where specific reversal unavailable. Andexanet alfa where locally available |
| Dabigatran | Idarucizumab 5 g IV |
| Warfarin | PCC 25–50 units/kg (guided by INR) + vitamin K 10 mg IV |
| UFH | Protamine (weight-based dosing) |
| LMWH | Protamine gives partial reversal (~60%) |
Full reversal protocols: Coagulation Profile · Massive Hemorrhage
Perioperative interruption
DOACs: interruption depends on bleeding risk, renal function, and agent
- not routinely bridged
- dabigatran: longer hold with reduced CrCl
- neuraxial: follow anaesthesia / local protocol
Warfarin: bridging not routine, including most AF, VTE, and mechanical-valve patients
- reserve for selected very-high-thrombotic-risk situations; involve the senior / specialty team
Educational reference for clinicians. Doses are typical adult starting points. Cross-check allergies, interactions, current local policy, the formulary, and renal/hepatic function before prescribing.
Last updated · September 2026