dalteparin (Rx)

Brand and Other Names:Fragmin
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Dosing & Uses

AdultPediatricGeriatric

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)

Next:

Interactions

Interaction Checker

and dalteparin

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    Interactions Found

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      Serious - Use Alternative

        Significant - Monitor Closely

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            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.

            • 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.

            • warfarin

              dalteparin and warfarin 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 (133)

            • 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.

            • 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.

            • caplacizumab

              caplacizumab, dalteparin. Either increases effects of the other by anticoagulation. 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.

            • 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.

            • 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 (17)

            • 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.

            • 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.

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            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

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            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 that have undergone epidural neuraxial anesthesia

            Cautions

            Risk of epidural/spinal hematoma if used in patients getting epidural/spinal anesthesia which may result in paralysis

            Use caution in conditions with increased risk of hemorrhage, hemorrhagic diathesis, severe uncontrolled HTN, severe hepatic/renal impairment, retinopathy, thrombocytopenia, bacterial endocarditis, GI ulcer, hemorrhagic stroke, recent brain, spinal or ophthalmologic surgery

            Periodic routine complete blood cell counts, including platelet count, blood chemistry, and stool occult blood tests are recommended during treatment

            History of heparin-induced thrombocytopenia

            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 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

            Therapy 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; monitor thrombocytopenia of any degree closely

            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

            For patients with CrCl <30 mL/min, elimination of dalteparin may be prolonged; consider doubling the timing of removal of a catheter, at least 24 hr for lower prescribed dose of dalteparin (2500 IU or 5000 IU qDay) and at least 48 hr for higher dose (200 IU/kg once daily, 120 IU/kg BID)

            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

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            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.

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            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)
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            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)
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            Images

            BRAND FORM. UNIT PRICE PILL IMAGE
            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
            -
            18,000 anti-Xa unit/0.72 mL solution
            Fragmin subcutaneous
            -
            12,500 anti-Xa unit/0.5 mL solution
            Fragmin subcutaneous
            -
            10,000 anti-Xa unit/mL solution
            Fragmin subcutaneous
            -
            10,000 anti-Xa unit/mL solution
            Fragmin subcutaneous
            -
            7,500 anti-Xa unit/0.3 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
            -
            2,500 anti-Xa unit/0.2 mL solution
            Fragmin subcutaneous
            -
            18,000 anti-Xa unit/0.72 mL solution
            Fragmin subcutaneous
            -
            25,000 anti-Xa unit/mL vial
            Fragmin subcutaneous
            -
            15,000 anti-Xa unit/0.6 mL solution
            Fragmin subcutaneous
            -
            12,500 anti-Xa unit/0.5 mL solution

            Copyright © 2010 First DataBank, Inc.

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            Patient Handout

            Patient Education
            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 persist or worsen, 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. Pregnant women with artificial heart valves need close monitoring (see Notes).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.Laboratory and/or medical tests (such as blood counts including hemoglobin, hematocrit and platelets, checking stool for blood) should be performed periodically to monitor your progress or check for side effects. Additional lab tests (anti-factor Xa blood levels) should be performed in certain cases, especially if you have kidney disease, are pregnant and have artificial heart valves, or to check if dalteparin is working well for you. 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 August 2021. Copyright(c) 2021 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.

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            Formulary

            FormularyPatient Discounts

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.