The dose of lepirudin (Refludan, Berlex) needs to be reduced for a patient with heparin-induced thrombocytopenia and renal insufficiency. The adjustment is based on the level of residual renal function.
NOTE: The maximum dose is not listed. For a patient with normal renal function, the maximum dose is achieved at a body weight of 110 kilograms. I will use this in the implementation, but this needs to be confirmed.
The aPTT ratio (see previous section) is performed on a patient prior to therapy. Therapy is not started if the ratio is >= 2.5.
For the patient with renal insufficiency but not being dialyzed:
|
Estimated Creatinine Clearance in mL per minute |
IV Bolus Dose to Administer in mg per kg body weight |
IV Infusion Rate in mg per kg per hour |
|
45 - 60 |
0.2 |
0.075 |
|
30 - 44 |
0.2 |
0.045 |
|
15 - 29 |
0.2 |
0.0225 |
|
< 15 |
not given |
not given |
If the patient is being hemodialyzed, then a bolus dose is given every other day ONLY if the aPTT ratio is < 1.5.
|
IV Bolus Dose to Administer in mg per kg body weight |
IV Infusion Rate in mg per kg per hour |
|
0.05 - 0.10 |
not given |
If the patient is critically ill and undergoing continuous venovenous hemodialysis, then:
|
IV Bolus Dose to Administer in mg per kg body weight |
IV Infusion Rate in mg per kg per hour |
|
0.007 - 0.025 |
0.006 - 0.009 |
The aPTT ratio is determined at 4 hours after initiating therapy. The target ratio is 2. If the ratio is < 1.5 or > 2.5, then the testing is repeated before the infusion is adjusted..
Specialty: Hematology Oncology, Clinical Laboratory, Pharmacology, clinical, Critical Care, Immunology/Rheumatology
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