Saturday, February 28, 2015

Study group discussion: Low molecular weight heparin vs unfractionated heparin

Something regarding heparins! So which one is better to use? LMWH or UFH? Why?

LMWH (Low molecular weight heparin)


Less incidence of thrombocytopenia with LMWH!
Better bioavailability, t1/2 , APTT not affected.

Right. Why APTT not affected?

Because LMWH has more predictable pharmacokinetics and anticoagulant effect, LMWH is recommended over unfractionated heparin for patients with massive pulmonary embolism.

Because LMWH acts only on AT3... Does not have the scaffolding effect of UFH.

On which part it doesn't act?
LMWH doesn't affect on thrombin..

Yes! That's the answer!

LMWH acts on AT3 only and doesn't affect thrombin.

UFH acts by 2 mechanisms
1. On AT3
2. By providing a scaffolding on which AT3 can interact with Thrombin

In LMWH, the second effect is absent, hence less interference...

Yes!! Correct!!

Which situation you would prefer UFH?

For cardiac surgeries, UFH is preferred as it can be titrated dose - by - dose with protamine sulphate.

Cardiopulmonary bypass.


Cardiopulmonary bypass....Because it's effects can easily be reversed fully by protamine. And its more effective.

Exactly! Any conditions with high risk of bleeding we prefer UFH.

Yep. Cause we will be able to reverse if we give more heparin by giving protamine sulphahte same is not possible with LMWHs.


Because action of LMWH cannot be reversed completely..

Yes, correct. It's because of the molecular weight.

So which test would you like to do before deciding whether to give UFH or LMWHs?

Any other conditions?

Ok so in cases of advanced renal failure UFH are preferred over LMWHs

Now tell me why?

No idea.. Please explain!

So we would check creatinine before starting heparin

This was the test I was taking about! LMWHs are excreted renally.

Right...UFH is metabolised by liver

On the other hand UFHs are cleared by reticuloendothelial system.

Good work guys! Hope it helped!

Yes, thanks a lot!

What about pregnancy?

Are UFH still preferred or do you give LMWH?

The major limiting factor is the cost or HIT. Heparin is still ruling the world and saving millions of lives.

Also i heard..senior doctors still prefer UFH, inspite of LMW

Ummm!! I would say LMWHs are much better!! Many trials have proved that! It's only in certain scenarios that UFHs are preffered. Nobody wants to keep monitoring APTT so just making the life easy LMWHs are good!!

Yeah. But they are more experienced in using UFH.
This was told by our residents. If a senior external asks you whether UFH or LMWH is better.. Be diplomatic in your answer.

Ohh! Yeah that can be the thing!

Updated later:
And also an addition to a previous discussion on oral anti-coagulants. Why heparin is given for the initial 5 to 7 days, when warfarin has already been started?
One reason is the preformed coagulant factors need to get depleted before warfarin starts taking effect. The other reason is that in the initial days warfarin acts as a prothombotic. Cause it depletes protein c and protein s!

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