PHYSICAN’S ORDERS: ARGATROBAN Orders for …

1 PHYSICAN S Orders : ARGATROBAN Orders for Patients with Heparin Induced Thrombocytopenia (HIT) For new starts - Complete first section of order form Initial Orders only. Complete second section Dosage Adjustment each time a dosing adjustment is necessary. Special Note: ARGATROBAN IS RESTRICTED TO HEMATOLOGIST and use caution in hepatic dysfunction. Suspect HIT : heparin > 5days 30-50% drop in platelet count or absolute platelet count <100,000 in patients with heparin new thromboembolic event on heparin 1. Initial Orders : patient weight. Weight = _____kg. 2. Discontinue ALL heparin therapy prior to starting ARGATROBAN [in addition to heparin infusion, all heparin flushes, heparin-coated catheters, dalteparin (Fragmin), enoxaparin (Lovenox)]. 3. Consider stopping aspirin, clopidogrel (Plavix), or other antiplatelet agents _____. 4.

2 No warfarin until recovery of platelets to within normal range (>140,000). 5. Obtain baseline PT, PTT, and LFT STAT. (If abnormal results call physician). 6. ARGATROBAN to begin when heparin effect eliminated per chart below Check Hours to wait Usual scenario 4 - 6 Patients on continuous IV heparin infusion 12 Patients on q 12 hour low molecular weight heparin 24 Patients on q 24 hour low molecular weight heparin 7. If PTT normal (less than 36): Start ARGATROBAN IV Infusion: 250mg/250ml normal saline (1mg/ml = 1000mcg/ml) Patients with hepatic dysfunction: ARGATROBAN should be used with caution. (Evaluate bleeding risk). Child-Pugh Score: Factor 1 2 3 Serum bilirubin (mg/dL) > Serum albumin (g/dL) > < Ascites None Easily controlled Poorly controlled Neurologic disorder None Minimal Advanced coma INR < > Patients with normal hepatic function: Initiate ARGATROBAN IV Continuous infusion at a rate of 2mcg/kg/min.

3 2mcg/kg/min x _____(kg) x 60 (min)/1000mcg/ml = _____ ml/hr. Hepatic impairment: (bili >2, Child-Pugh >6) consider starting at mcg/kg/min. x _____ (kg) x 60 (min)/1000mcg/ml = _____ml/hr. Renal impairment: No adjustment is needed. 8. Order STAT PTT 2hr after starting ARGATROBAN infusion. Call hematologists/physician with results. 9. Target PTT is 46-70 sec (PTT to 3 times baseline). PTT not to exceed 100 seconds. 10. Dosage adjustment: Physician to order dosage adjustment based on results of PTT. Physician Signature _____ Date_____ Time_____ 2. ARGATROBAN DOSING ADJUSTMENT FORM: 11. DOSING ADJUSTMENT FOR ARGATROBAN INFUSION PTT Intervention Monitoring 35-45 Increase infusion rate by (If hepatic impairment increase by ) New rate: _____mcg/kg/minute. PTT Q3 hours x 2, then Q12 hours 46-70 No dose change. Continue current infusion rate. Obtain daily PTT. PTT Q12 hours x 2, then daily 71 and higher Stop infusion for 1 hr.

4 Decrease infusion rate by (Decrease by for patients with hepatic impairment) New rate: _____mcg/kg/min. PTT Q3 hours x 2, then Q12 hours *Rate is not to exceed 10 mcg/kg/min; maximum dosing weight is 140 kg 12. CBC daily while on ARGATROBAN . 3. ARGATROBAN Conversion to Warfarin Orders Make sure platelet count is within normal limits. Recognize combined effects on INR of ARGATROBAN and warfarin. Obtain baseline INR on ARGATROBAN . Begin oral warfarin at expected daily dose (usually 5mg or ) PO daily at 13:00. A loading dose of warfarin should not be used. INR level daily. If INR < 4, continue combined warfarin and ARGATROBAN therapy, recheck in 24 hours If INR > 4: A. for patients on ARGATROBAN < 2mcg/kg/min stop ARGATROBAN infusion recheck INR in 4-6 hours if warfarin-alone INR < 2, then restart ARGATROBAN at previous rate and recheck in 24 hours if warfarin-alone INR > 2, then stop ARGATROBAN B. for patients on ARGATROBAN > 2 mcg/kg/min reduce dose of ARGATROBAN to 2 mcg/kg/min recheck INR and PTT in 4-6 hours if INR still > 4 than mange as in A.

5 If INR now < 4 then continue ARGATROBAN and titrate to PTT times original base INR can be falsely elevated during the infusion of ARGATROBAN due to an interaction with laboratory reagents. The following formula may be used to predict the true INR (valid only for doses of ARGATROBAN < 2mcg/kg/min. + ( x reported INR) _____ = _____ true INR 4. If any questions call pharmacy. 5. If any bleeding HOLD ARGATROBAN and call physician. Physician Signature _____ Date _____ Time _____ ARGATROBAN 250mg/250ml Normal Saline (1000 mcg/ml) Dose (mcg/kg/min) 1 2 3 4 5 Weight (kg) Infusion rates (ml/hr) 40 6 12 45 50 3 6 9 12 15 55 60 9 18 65 70 21 75 9 18 80 12 24 85 90 27 95 100 3 6 9 12 15)

6 18 21 24 27 30 105 110 33 115 120 18 36 125 15 30 130 39 135 140 21 42