Heparin – Low Molecular Weight (LMWH) (Various) – For patients requiring long term anticoagulation in whom warfarin is contraindicated or inappropriate

NICE recommendations, summary of meeting discussions, links to additional supporting docs etc.

(Dalteparin, Enoxaparin, Tinzaparin)

March 2008:

Indication for Shared Care:

If an individual requires more than a few days anticoagulation treatment they are generally switched to oral therapy with warfarin. However there are certain situations where the prolonged use of heparin may be indicated:

* medium to long-term thromboprophylaxis for patients in whom oral anticoagulation is contraindicated (e.g. pregnancy).

* treatment of venous thromboembolism for patients in whom oral anticoagulation is contraindicated/ineffective (e.g. in pregnancy, certain patients with cancer, poor compliance.)

In these circumstances therapy with LMWH, which does not cross the placenta and is not interfered with by alcohol or other drugs, can be given subcutaneously.

A shared care agreement has been endorsed by haematology departments at the JPUH, NNUH and QEH.

Criteria for Patient Selection:

Patients requiring therapeutic or prophylactic anticoagulation who:

1. are pregnant (risk of teratogenicity with warfarin; other OACs not licensed)

2. have poor compliance/life style e.g. alcoholism and drug addiction

3. have high risk of bleeding e.g. existing thrombocytopenia / certain patients with cancer e.g. receiving myelosuppressive treatment

4. have thrombosis which is not controlled by an oral anticoagulant e.g. certain patients with cancer

September 2014: The TAG considered and supported a revised version of the local Shared Care Agreement which had been updated in line with current manufacturers’ SPCs. The TAG agreed that it should be published as an interim agreement until wider commissioning arrangements are finalised.

September 2017:  The revised draft of the shared care agreement had been reviewed and updated in line with the manufacturer’s SPCs. No further recommendations for changes had been received from the authors / local specialists.

The TAG supported its continued use and confirmed a classification of Amber (Option for GP prescribing under an approved shared care agreement).

September 2017:  The NHS Norfolk & Waveney CCGs’ D&TCG noted and supported the TAG recommendation.