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● To reduce bleedings avoid fondaparinux and dabigatran during renal impairment and generally use low molecular weight heparins (LMWH) with larger molecules.
● Adjust dosage of LMWH and new oral anticoagulants as recommended for a given drug at low estimated GFR values.
● Monitor the effect of LMWH using factor Xa activity during renal or hepatic impairment, pregnancy, in cases of obesity, and in children.
● Determine INR every 3 weeks in every warfarin/phenprocoumon-treated patient and more frequently upon any co-medication changes or after INR value derangements. Make sure that warfarin/phenprocoumon-treated patients understand why they must not commence, interrupt, or dose-adjust any concomitant treatment without consulting a physician.
● Use protamine in cases of serious LMWH-related bleedings, but do not overdose (anticoagulant effect). Temporarily interrupt treatment and give vitamin K during mild warfarin/phenprocoumon-related bleedings and fresh frozen plasma in life-threatening cases.
● To reduce the complications of type II heparin-induced thrombocytopenia (HIT II) measure the platelet number twice per week in all heparin-treated patients (both unfractionated and LMWH) in the first 3 weeks. At HIT II diagnosis replace heparin with argatroban (replacement with fondaparinux is off-label). HIT I resolves spontaneously and requires no drug replacement.