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Unfractionated Heparin (UFH): Uses, Dosage, Side Effects & Safety | DrugsAtlas

Authoritative Clinical Reference

Therapeutic Class

Anticoagulant

Subclass

Indirect thrombin inhibitor (via antithrombin III potentiation)

Speciality

Haematology

Schedule (India)

Schedule H

Routes

Intravenous (IV), Subcutaneous (SC)

Formulations

Injection: 5,000 IU/mL (1 mL, 5 mL vials/ampoules)
Injection: 25,000 IU/5 mL (5 mL vials)

Adult indications

INDICATIONS + DOSING — FOR CLINICIAN USE ONLY

Primary Indications (Approved / Standard in India)

1. Venous Thromboembolism (VTE) Prophylaxis in High-Risk Patients

Parameter	Recommendation
Starting dose	5,000 IU SC
Titration	Not applicable
Usual maintenance dose	5,000 IU SC every 8–12 hours
Maximum dose	5,000 IU every 8 hours

Clinical Notes:

Initiate post-operatively once haemostasis is secured
Continue until patient is ambulatory or transitioned to oral anticoagulation
No aPTT monitoring required for prophylactic dosing

2. Treatment of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

Weight-based Protocol (Preferred):

Parameter	Recommendation
Starting dose	80 IU/kg IV bolus
Titration	Adjust infusion rate every 6 hours based on aPTT (target: 1.5–2.5× control or 60–80 seconds)
Usual maintenance dose	18 IU/kg/hour continuous IV infusion
Maximum dose	Titrate to therapeutic aPTT; no fixed ceiling

Fixed-dose Protocol (Alternative):

Parameter	Recommendation
Starting dose	5,000–10,000 IU IV bolus
Titration	Adjust based on aPTT every 6 hours until stable
Usual maintenance dose	1,000–1,500 IU/hour continuous IV infusion
Maximum dose	As per aPTT response

Clinical Notes:

Check aPTT 6 hours after initiation and after each dose adjustment
Once stable, monitor aPTT daily
Overlap with oral anticoagulant (warfarin) for minimum 5 days and until INR ≥2 for 24 hours

3. Acute Coronary Syndromes (Unstable Angina / NSTEMI)

Parameter	Recommendation
Starting dose	60–70 IU/kg IV bolus (maximum 5,000 IU)
Titration	Adjust infusion based on aPTT (target: 1.5–2.5× control)
Usual maintenance dose	12–15 IU/kg/hour IV infusion (maximum 1,000 IU/hour)
Maximum dose	1,000 IU/hour (higher doses increase bleeding without added benefit)

Clinical Notes:

Duration: 2–5 days or until revascularisation
Co-administer with antiplatelet therapy (aspirin ± P2Y12 inhibitor) as per ACS protocol
Monitor for bleeding complications at vascular access sites

4. Anticoagulation During Percutaneous Coronary Intervention (PCI)

Parameter	Recommendation
Starting dose	70–100 IU/kg IV bolus (without GP IIb/IIIa inhibitor) OR 50–70 IU/kg IV bolus (with GP IIb/IIIa inhibitor)
Titration	Additional boluses guided by ACT
Usual maintenance dose	Not applicable (bolus-only protocol)
Maximum dose	Guided by ACT (target: 250–350 seconds without GP IIb/IIIa; 200–250 seconds with GP IIb/IIIa)

5. Anticoagulation During Cardiopulmonary Bypass (CPB)

Parameter	Recommendation
Starting dose	300–400 IU/kg IV bolus before cannulation
Titration	Additional boluses to maintain ACT >400–480 seconds
Usual maintenance dose	As per intra-operative ACT monitoring
Maximum dose	Guided by ACT; typically 600 IU/kg total may be required

Clinical Notes:

Protamine reversal required post-bypass
Protamine dose: 1 mg per 100 IU of heparin administered

6. Anticoagulation During Haemodialysis

Parameter	Recommendation
Starting dose	1,000–2,000 IU IV bolus at initiation
Titration	Additional 500–1,000 IU if session prolonged
Usual maintenance dose	500–1,000 IU/hour during dialysis
Maximum dose	Individualised based on clotting in circuit

Clinical Notes:

Reduce dose or use heparin-free dialysis in patients with high bleeding risk
UFH preferred over LMWH in dialysis due to reversibility

Secondary Indications — Adults (Off-label, if any)

Indication	Dose	Duration	Label Status	Evidence Basis
Disseminated Intravascular Coagulation (DIC) with predominant thrombotic features	5,000 IU SC every 8–12 hours; adjust based on clinical and laboratory response	Until DIC resolution	OFF-LABEL; Specialist only	Indian specialist haematology practice; selected case series
Cerebral venous sinus thrombosis	Weight-based IV protocol as per DVT treatment	Until transition to oral anticoagulation	OFF-LABEL; Specialist only	AIIMS neurology protocols; international guidelines

Paediatric indications

PAEDIATRIC DOSING (Specialist Only)

Primary Indications (Approved / Standard in India)

Treatment of DVT/PE in Children

Age Group	Loading Dose (IV over 10 min)	Maintenance Infusion (IV)	Target aPTT
Neonates (<28 days)	75–100 IU/kg	28 IU/kg/hour	60–85 seconds
Infants (28 days–1 year)	75 IU/kg	20 IU/kg/hour	60–85 seconds
Children (>1 year)	75 IU/kg	18 IU/kg/hour	60–85 seconds

Titration Protocol:

Check aPTT 4–6 hours after initiation
Adjust infusion by 10–25% increments based on aPTT
Recheck aPTT 4–6 hours after each dose change until stable

Safety Monitoring:

Platelet count at baseline, day 3, and then every 2–3 days
Monitor for signs of bleeding (mucosal, injection sites, intracranial in neonates)
Anti-Xa levels may be used if aPTT unreliable (target: 0.35–0.7 IU/mL)

Secondary Indications — Paediatrics (Off-label, if any)

Indication	Dose	Duration	Label Status	Evidence Basis
Central venous catheter patency (flush)	10 IU/mL; flush every 8–12 hours	As long as catheter in situ	OFF-LABEL; Specialist only	Indian PICU practice; IAP recommendations
Kawasaki disease with coronary aneurysm	Weight-based therapeutic protocol	Until transition to LMWH or warfarin	OFF-LABEL; Specialist only	Indian paediatric cardiology practice

Age Restriction: Not recommended in neonates except under specialist haematology or neonatology supervision with appropriate monitoring facilities.

Renal Adjustments

Renal Function	Recommendation
Mild-to-moderate impairment (eGFR 30–89 mL/min)	No dose adjustment required
Severe impairment (eGFR <30 mL/min)	No dose adjustment; UFH preferred over LMWH in this population
Haemodialysis	Use as per dialysis anticoagulation protocol; preferred agent due to short half-life and reversibility
Peritoneal dialysis	Standard dosing; monitor for bleeding

Clinical Note: Despite renal-independent clearance, monitor aPTT closely in severe renal impairment due to altered protein binding and comorbidities affecting bleeding risk.

Hepatic adjustment

Contraindications

Active major bleeding (gastrointestinal, intracranial, retroperitoneal)
Severe uncontrolled hypertension
History of heparin-induced thrombocytopenia (HIT) type II
Hypersensitivity to heparin or porcine-derived products
Recent haemorrhagic stroke or intracranial haemorrhage
Severe thrombocytopenia (platelet count <50,000/μL unless thrombotic emergency)
Recent lumbar puncture or spinal anaesthesia (within 12–24 hours)
Threatened abortion

Cautions

Recent major surgery or trauma (within 7–14 days)
Active peptic ulcer disease or history of GI bleeding
Severe liver disease with coagulopathy
Bacterial endocarditis
Diabetic retinopathy with risk of vitreous haemorrhage
Concurrent use of antiplatelet agents
Indwelling epidural catheters
Advanced age (>75 years) — increased bleeding risk
History of allergy to beef or pork products
Prior exposure to heparin within 100 days — increased HIT risk

Pregnancy

Parameter	Recommendation
Safety status	Safe in pregnancy — does not cross placenta
Preferred use	Unidentified
Alternatives	LMWH is more commonly used due to convenient dosing; UFH preferred near delivery for reversibility
When to use	Throughout pregnancy; switch from LMWH to UFH at 36 weeks or before planned delivery
Monitoring	aPTT (therapeutic dosing); platelet count every 2–3 days; signs of bleeding; osteoporosis risk with prolonged use

Lactation

Parameter	Recommendation
Compatibility	Compatible with breastfeeding
Drug levels in milk	Negligible; large molecular weight prevents transfer
Preferred alternative	LMWH is equally safe; both acceptable
Infant monitoring	No specific monitoring required

Elderly

Starting dose: Use lower end of dosing range; consider 60 IU/kg bolus and 15 IU/kg/hour infusion for therapeutic anticoagulation
Titration: More gradual; increase intervals between dose adjustments
Extra risks:
- Increased bleeding risk due to age-related vascular fragility
- Reduced renal reserve affecting drug handling
- Higher incidence of falls and trauma
- Greater sensitivity to anticoagulant effect
- Polypharmacy increasing interaction risk
Monitoring: More frequent aPTT checks; vigilant clinical monitoring for bleeding

Major drug interactions

Interacting Drug/Class	Mechanism/Effect	Recommendation
Antiplatelet agents (aspirin, clopidogrel, prasugrel, ticagrelor)	Synergistic bleeding risk	Use cautiously; essential in ACS protocols but monitor closely
Oral anticoagulants (warfarin, acenocoumarol)	Additive anticoagulation	Overlap briefly during transition; monitor INR and aPTT
Direct oral anticoagulants (rivaroxaban, apixaban, dabigatran)	Excessive anticoagulation	Avoid concurrent use except during protocol-guided transitions
Thrombolytics (alteplase, streptokinase, tenecteplase)	Markedly increased bleeding	Use sequentially, not concurrently; heparin started after thrombolysis per protocol
GP IIb/IIIa inhibitors (abciximab, eptifibatide, tirofiban)	Synergistic bleeding	Reduce heparin dose during PCI; monitor ACT
Dextran	Additive anticoagulant effect	Avoid combination

Moderate drug interactions

Interacting Drug/Class	Mechanism/Effect	Recommendation
NSAIDs (diclofenac, ibuprofen, naproxen)	Increased GI bleeding risk; platelet inhibition	Monitor for bleeding; avoid if possible
SSRIs/SNRIs (fluoxetine, sertraline, venlafaxine)	Impaired platelet function	Monitor for bleeding
Nitroglycerin (IV)	May reduce heparin effect; mechanism unclear	May require higher heparin doses; monitor aPTT
Penicillins (high-dose piperacillin, ticarcillin)	Platelet dysfunction	Monitor bleeding time and clinical signs
Tetracyclines, antihistamines	May interfere with aPTT assay	Interpret aPTT cautiously

Common Adverse effects

Bleeding (injection site haematoma, gingival bleeding, epistaxis, haematuria)
Injection site pain and erythema (SC administration)
Mild transient thrombocytopenia (non-immune, within first 2 days)
Elevated transaminases (mild, reversible)
Bruising

Serious Adverse effects

Heparin-induced thrombocytopenia (HIT) type II: Immune-mediated; platelet drop >50% from baseline typically day 5–10; paradoxically causes thrombosis — discontinue heparin immediately; initiate alternative anticoagulant (argatroban, fondaparinux)
Major haemorrhage: Intracranial, retroperitoneal, GI — requires protamine reversal and supportive care
Osteoporosis: With prolonged use (>1 month); vertebral fractures reported
Skin necrosis: At injection sites; rare
Hypersensitivity reactions: Urticaria, anaphylaxis (rare)
Hyperkalaemia: Due to aldosterone suppression; monitor potassium in prolonged use

Monitoring requirements

Timing	Parameters
Baseline	CBC with platelet count, aPTT, PT/INR, serum creatinine, LFTs
After initiation/dose change	aPTT every 6 hours until therapeutic and stable (2 consecutive values in range)
Ongoing (therapeutic dosing)	aPTT daily once stable; platelet count every 2–3 days for first 14 days (HIT surveillance)
Ongoing (prophylactic dosing)	Platelet count every 2–3 days; no routine aPTT required
Prolonged use (>1 month)	Consider bone density monitoring; serum potassium
Clinical	Daily assessment for bleeding, thrombosis, injection site reactions

Brands in India

Heparin Sodium Injection IP (Gland Pharma, Biological E, Gufic, VHB Lifesciences)
Heparin Leo® (Leo Pharma)
Beparine® (Troikaa)
Hepaglan® (Gland Pharma)
Multiple institutional and generic manufacturers

Price range (INR)

Formulation	Approximate Price	Notes
5,000 IU/mL (1 mL vial)	₹15–40 per vial	NLEM-listed; price controlled
25,000 IU/5 mL (5 mL vial)	₹50–100 per vial	NLEM-listed; price controlled

NLEM Status: Included in NLEM 2022; available through government supply under NHM and institutional procurement.

Clinical pearls

UFH is preferred over LMWH in severe renal impairment (eGFR <30 mL/min), high bleeding risk situations, and when rapid reversibility is needed (surgery, delivery)
Protamine sulfate reverses UFH: 1 mg neutralises approximately 100 IU of heparin given in the preceding hour; reduce dose for heparin given earlier
HIT typically occurs day 5–14 of exposure; always check prior heparin exposure history — patients exposed within 100 days may develop rapid-onset HIT
Weight-based dosing protocols achieve therapeutic aPTT faster and more reliably than fixed-dose protocols
In obese patients, use actual body weight for bolus but consider dose-capping the infusion rate
Never mix heparin with other IV medications unless compatibility is confirmed; use dedicated IV line or flush between drugs

Version

RxIndia v1.0 — 28 May 2025

Reference

- CDSCO product information
- Indian Pharmacopoeia
- NLEM 2022
- AIIMS Anticoagulation Guidelines
- API Textbook of Medicine
- ICMR/National Guidelines for Management of VTE
- Indian Society of Haematology and Blood Transfusion (ISHBT) protocols
- Cardiological Society of India (CSI) ACS management guidelines

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Clinical Responsibility

This platform is designed strictly for healthcare professionals. Data provided is synthesized from authoritative pharmacological sources and clinical registries. Do not use for consumer medical decisions. Always verify critical dosing and contraindications with official institutional protocols and peer-reviewed journals.

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