These Highlights Do Not Include All The Information Needed To Use Heparin Sodium Injection Safely And Effectively. See Full Prescribing Information For Heparin Sodium Injection.

Heparin can suppress adrenal secretion of aldosterone leading to hyperkalemia, particularly in patients with diabetes mellitus, chronic renal failure, pre-existing metabolic acidosis, a raised plasma potassium, or taking potassium sparing drugs. The risk of hyperkalemia appears to increase with duration of therapy but is usually reversible upon discontinuation of heparin.

Measure blood potassium in patients at risk of hyperkalemia before starting heparin therapy and periodically in all patients treated for more than 5 days or earlier as deemed fit by the clinician.

Store at 20° to 25°C (68° to 77°F). [See USP Controlled Room Temperature.]

Do not place syringe on a sterile field.

Discard unused portion.

Sterile, Nonpyrogenic.

The container closure is not made with natural rubber latex.

Principal Display Panel – Heparin Sodium Injection, USP 5,000 USP units per mL Syringe Label

For Intravenous or Subcutaneous Use

1 mL Prefilled Single-Dose Syringe

FROM PORCINE INTESTINAL MUCOSA

Mfd. For Meitheal Pharmaceuticals

NDC 71288-406-81

Rx Only

Heparin Sodium Injection, USP

5,000 USP units per mL

NOT for Lock Flush

Bleeding is the chief sign of heparin sodium overdosage.

Heparin is a heterogeneous group of straight-chain anionic mucopolysaccharides, called glycosaminoglycans, possessing anticoagulant properties. It is composed of polymers of alternating derivations of α-D-glucosamido (N-sulfated O-sulfated or N-acetylated) and O-sulfated uronic acid (α-L-iduronic acid or β-D-glucuronic acid).

Structure of heparin sodium (representative subunits):

Heparin Sodium Injection, USP is a sterile solution of heparin sodium derived from porcine intestinal mucosa, standardized for anticoagulant activity. It is to be administered by intravenous or deep subcutaneous routes. The potency is determined by a biological assay using a USP reference standard based on units of heparin activity per milligram.

Heparin Sodium Injection, USP preserved with benzyl alcohol, is available in the following concentrations per mL:

pH 5.0 to 7.5; sodium hydroxide and/or hydrochloric acid added, if needed, for pH adjustment.

Avoid using heparin sodium in the presence of major bleeding, except when the benefits of heparin therapy outweigh the potential risks.

Hemorrhage can occur at virtually any site in patients receiving heparin sodium. Fatal hemorrhages have occurred. Adrenal hemorrhage (with resultant acute adrenal insufficiency), ovarian hemorrhage, and retroperitoneal hemorrhage have occurred during anticoagulant therapy with heparin sodium [see Adverse Reactions (6.1)]. A higher incidence of bleeding has been reported in patients, particularly women, over 60 years of age [see Clinical Pharmacology (12.3)]. An unexplained fall in hematocrit, fall in blood pressure or any other unexplained symptom should lead to serious consideration of a hemorrhagic event.

Use heparin sodium with caution in disease states in which there is increased risk of hemorrhage, including:

• Cardiovascular - Subacute bacterial endocarditis, severe hypertension.
• Surgical - During and immediately following (a) spinal tap or spinal anesthesia or (b) major surgery, especially involving the brain, spinal cord, or eye.
• Hematologic - Conditions associated with increased bleeding tendencies, such as hemophilia, thrombocytopenia and some vascular purpuras.
• Patients with hereditary antithrombin III deficiency receiving concurrent antithrombin III therapy - The anticoagulant effect of heparin sodium is enhanced by concurrent treatment with antithrombin III (human) in patients with hereditary antithrombin III deficiency. To reduce the risk of bleeding, reduce the heparin sodium dose during concomitant treatment with antithrombin III (human).
• Gastrointestinal - Ulcerative lesions and continuous tube drainage of the stomach or small intestine.
• Other - Menstruation, liver disease with impaired hemostasis.

Do not use benzyl alcohol-preserved drugs in neonates and infants. Use preservative-free heparin sodium injection in neonates and infants [see Warnings and Precautions (5.4)].

There are no adequate and well controlled studies on heparin sodium use in pediatric patients. Pediatric dosing recommendations are based on clinical experience. In general, the following dosage schedule may be used as a guideline in pediatric patients:

There are no adequate and well controlled studies on heparin sodium use in pediatric patients. Pediatric dosing recommendations are based on clinical experience [see Dosage and Administration (2.5)].

Carefully examine all heparin sodium injection syringes to confirm choice of the correct strength prior to administration of the drug. Pediatric patients, including neonates, have died as a result of medication errors in which heparin sodium injection vials have been confused with “catheter lock flush” vials [see Warnings and Precautions (5.1)].

There are limited adequate and well-controlled studies in patients 65 years and older, however, a higher incidence of bleeding has been reported in patients, particularly women, over 60 years of age [see Warnings and Precautions (5.2)]. Patients over 60 years of age may require lower doses of heparin sodium.

Lower doses of heparin sodium may be indicated in these patients [see Clinical Pharmacology (12.3)].

The use of heparin sodium is contraindicated in patients with the following conditions:

• History of heparin-induced thrombocytopenia and heparin-induced thrombocytopenia and thrombosis [see Warnings and Precautions (5.3)];
• Known hypersensitivity to heparin sodium or pork products (e.g., anaphylactoid reactions) [see Adverse Reactions (6.1)];
• In whom suitable blood coagulation tests, e.g., the whole blood clotting time, partial thromboplastin time, etc., cannot be performed at appropriate intervals (this contraindication refers to full-dose heparin sodium; there is usually no need to monitor coagulation parameters in patients receiving low-dose heparin sodium);
• An uncontrolled active bleeding state [see Warnings and Precautions (5.2)], except when this is due to disseminated intravascular coagulation.

The following clinically significant adverse reactions are described elsewhere in the labeling:

• Hemorrhage [see Warnings and Precautions (5.2)]
• Heparin-Induced Thrombocytopenia and Heparin-Induced Thrombocytopenia and Thrombosis [see Warnings and Precautions (5.3)]
• Risk of Serious Adverse Reactions in Infants Due to Benzyl Alcohol Preservative [see Warnings and Precautions (5.4)]
• Thrombocytopenia [see Warnings and Precautions (5.5)]
• Heparin Resistance [see Warnings and Precautions (5.7)]
• Hypersensitivity [see Warnings and Precautions (5.8)]
• Hyperkalemia [see Warnings and Precautions (5.9)]

Drugs that interfere with platelet aggregation: May induce bleeding (7.2)

Thrombocytopenia in patients receiving heparin sodium has been reported at frequencies up to 30%. It can occur 2 to 20 days (average 5 to 9) following the onset of heparin therapy. Obtain platelet counts before and periodically during heparin therapy. Monitor thrombocytopenia of any degree closely. If the count falls below 100,000/mm³ or if recurrent thrombosis develops, promptly discontinue heparin sodium, evaluate for HIT and HITT, and, if necessary, administer an alternative anticoagulant [see Warnings and Precautions (5.3)].

Patients with documented hypersensitivity to heparin sodium should be given the drug only in clearly life-threatening situations.

Because heparin sodium injection is derived from animal tissue, it should be used with caution in patients with a history of allergy.

Various times (activated clotting time, activated partial thromboplastin time, prothrombin time, whole blood clotting time) are prolonged by full therapeutic doses of heparin sodium; in most cases, they are not measurably affected by low doses of heparin sodium. The bleeding time is usually unaffected by heparin sodium.

Absorption

Heparin sodium is not absorbed through the gastrointestinal tract and therefore administered via parenteral route. Peak plasma concentration and the onset of action are achieved immediately after intravenous administration.

Add 450 USP units to 600 USP units of heparin sodium per 100 mL of whole blood to prevent coagulation. Usually, 7,500 USP units of heparin sodium are added to 100 mL of 0.9% Sodium Chloride Injection, USP (or 75,000 USP units per 1,000 mL of 0.9% Sodium Chloride Injection, USP) and mixed; from this sterile solution, 6 mL to 8 mL are added per 100 mL of whole blood.

Resistance to heparin sodium is frequently encountered in fever, thrombosis, thrombophlebitis, infections with thrombosing tendencies, myocardial infarction, cancer, in postsurgical patients, and patients with antithrombin III deficiency. Close monitoring of coagulation tests is recommended in these cases. Adjustment of heparin sodium doses based on anti-Factor Xa levels may be warranted.

Digitalis, tetracyclines, nicotine or antihistamines may partially counteract the anticoagulant action of heparin sodium. Intravenous nitroglycerin administered to heparinized patients may result in a decrease of the partial thromboplastin time with subsequent rebound effect upon discontinuation of nitroglycerin. Careful monitoring of partial thromboplastin time and adjustment of heparin sodium dosage are recommended during coadministration of heparin sodium and intravenous nitroglycerin.

Antithrombin III (human) – The anticoagulant effect of heparin sodium is enhanced by concurrent treatment with antithrombin III (human) in patients with hereditary antithrombin III deficiency. To reduce the risk of bleeding, a reduced dosage of heparin sodium is recommended during treatment with antithrombin III (human).

Heparin Sodium Injection is indicated for:

• Prophylaxis and treatment of venous thrombosis and pulmonary embolism;
• Prevention of postoperative deep venous thrombosis and pulmonary embolism in patients undergoing major abdominothoracic surgery or who, for other reasons, are at risk of developing thromboembolic disease;
• Atrial fibrillation with embolization;
• Treatment of acute and chronic consumptive coagulopathies (disseminated intravascular coagulation);
• Prevention of clotting in arterial and cardiac surgery;
• Prophylaxis and treatment of peripheral arterial embolism.
• Anticoagulant use in blood transfusions, extracorporeal circulation, and dialysis procedures.

Heparin sodium may prolong the one-stage prothrombin time. Therefore, when heparin sodium is given with dicumarol or warfarin sodium, a period of at least 5 hours after the last intravenous dose or 24 hours after the last subcutaneous dose should elapse before blood is drawn, if a valid prothrombin time is to be obtained.

Drugs such as NSAIDS (including salicylic acid, ibuprofen, indomethacin, and celecoxib), dextran, phenylbutazone, thienopyridines, dipyridamole, hydroxychloroquine, glycoprotein IIb/IIIa antagonists (including abciximab, eptifibatide, and tirofiban), and others that interfere with platelet-aggregation reactions (the main hemostatic defense of heparinized patients) may induce bleeding and should be used with caution in patients receiving heparin sodium. To reduce the risk of bleeding, a reduction in the dose of antiplatelet agent or heparin sodium is recommended.

Heparin sodium interacts with the naturally occurring plasma protein, Antithrombin III, to induce a conformational change, which markedly enhances the serine protease activity of Antithrombin III, thereby inhibiting the activated coagulation factors involved in the clotting sequence, particularly Xa and IIa. Small amounts of heparin sodium inhibit Factor Xa, and larger amounts inhibit thrombin (Factor IIa). Heparin sodium also prevents the formation of a stable fibrin clot by inhibiting the activation of the fibrin stabilizing factor. Heparin sodium does not have fibrinolytic activity; therefore, it will not lyse existing clots.

Patients undergoing total body perfusion for open-heart surgery should receive an initial dose of not less than 150 units of heparin sodium per kilogram of body weight. Frequently, a dose of 300 units per kilogram is used for procedures estimated to last less than 60 minutes, or 400 units per kilogram for those estimated to last longer than 60 minutes.

To ensure continuous anticoagulation when converting from heparin sodium injection to warfarin, continue full heparin therapy for several days until the INR (prothrombin time) has reached a stable therapeutic range. Heparin therapy may then be discontinued without tapering [see Drug Interactions (7.1)].

• Fatal Medication Errors: Confirm choice of correct strength prior to administration (5.1)
• Hemorrhage: Fatal cases have occurred. Use caution in conditions with increased risk of hemorrhage (5.2)
• HIT and HITT: Monitor for signs and symptoms and discontinue if indicative of HIT and HITT (5.3)
• Benzyl Alcohol Toxicity: Do not use benzyl alcohol-preserved drugs in neonates and infants. (5.4)
• Monitoring: Blood coagulation tests guide therapy for full-dose heparin sodium.
• Monitor platelet count and hematocrit in all patients receiving heparin sodium (5.5, 5.6)
• Hyperkalemia: Measure blood potassium in patients at risk of hyperkalemia before starting heparin therapy and periodically in all patients (5.9)

Recommended Adult Dosages:

• Therapeutic Anticoagulant Effect with Full-Dose Heparin Sodium^† (2.4)

Do not use heparin sodium injection as a “catheter lock flush” product. Heparin sodium injection is supplied in syringes containing 5,000 units in 1 mL. Fatal hemorrhages have occurred in pediatric patients due to medication errors in which 1 mL heparin sodium injection vials were confused with 1 mL “catheter lock flush” vials. Carefully examine all heparin sodium injection syringes to confirm the correct syringe choice prior to administration of the drug.

Follow equipment manufacturers' operating directions carefully. A dose of 25 units/kg to 30 units/kg followed by an infusion rate of 1,500 units/hour to 2,000 units/hour is suggested based on pharmacodynamic data if specific manufacturers' recommendations are not available.

Heparin Sodium Injection, USP is available as 5,000 USP units in a 1 mL prefilled single-dose syringe, preserved with benzyl alcohol.

The following adverse reactions have been identified during post approval use of heparin sodium injection. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

• Hemorrhage is the chief complication that may result from heparin therapy [see Warnings and Precautions (5.2)]. Gastrointestinal or urinary tract bleeding during anticoagulant therapy may indicate the presence of an underlying occult lesion. Bleeding can occur at any site but certain specific hemorrhagic complications may be difficult to detect:
  • Adrenal hemorrhage, with resultant acute adrenal insufficiency, has occurred with heparin therapy, including fatal cases.
  • Ovarian (corpus luteum) hemorrhage developed in a number of women of reproductive age receiving short- or long-term heparin therapy.
  • Retroperitoneal hemorrhage
• HIT and HITT, including delayed onset cases [see Warnings and Precautions (5.3)].
• Local Irritation – Local irritation, erythema, mild pain, hematoma or ulceration may follow deep subcutaneous (intrafat) injection of heparin sodium. Because these complications are much more common after intramuscular use, the intramuscular route is not recommended.
• Histamine-like reactions – Such reactions have been observed at the site of injections. Necrosis of the skin has been reported at the site of subcutaneous injection of heparin sodium, occasionally requiring skin grafting [see Warnings and Precautions (5.3)].
• Hypersensitivity – Generalized hypersensitivity reactions have been reported, with chills, fever and urticaria as the most usual manifestations, and asthma, rhinitis, lacrimation, headache, nausea and vomiting, and anaphylactoid reactions, including shock, occurring less frequently. Itching and burning, especially on the plantar side of the feet, may occur [see Warnings and Precautions (5.8)].
• Elevations of aminotransferases – Significant elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels have occurred in patients who have received heparin sodium.
• Miscellaneous - Osteoporosis following long-term administration of high doses of heparin sodium, cutaneous necrosis after systemic administration, suppression of aldosterone synthesis, delayed transient alopecia, priapism, and rebound hyperlipemia on discontinuation of heparin sodium have also been reported.
• Metabolism and Nutrition Disorders – Hyperkalemia.

• Pregnancy: Preservative-free formulation recommended. Limited human data in pregnant women. (8.1)
• Lactation: Advise females not to breastfeed. (8.2)
• Pediatric Use: Use preservative-free formulation in neonates and infants. (8.4)
• Geriatric Use: A higher incidence of bleeding reported in patients, particularly women, over 60 years of age. (8.5)

Confirm the choice of the correct heparin sodium injection syringe to ensure that the 1 mL syringe is not confused with a “catheter lock flush” syringe or other 1 mL syringe of incorrect strength [see Warnings and Precautions (5.1)]. Confirm the selection of the correct formulation and strength prior to administration of the drug.

To lessen this risk, the 1 mL syringe includes a red cautionary statement. Read the cautionary statement and confirm that you have selected the correct medication and strength.

When heparin sodium injection is added to an infusion solution for continuous intravenous administration, invert the container repeatedly to ensure adequate mixing and prevent pooling of the heparin sodium in the solution.

Inspect parenteral drug products visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Use only if solution is clear and the seal is intact. Do not use if solution is discolored or contains a precipitate.

Administer heparin sodium injection by intermittent intravenous injection, intravenous infusion, or deep subcutaneous (intrafat, i.e., above the iliac crest or abdominal fat layer) injection. Do not administer heparin sodium injection by intramuscular injection because of the risk of hematoma at the injection site [see Adverse Reactions (6)].

Heparin Sodium Injection, USP preserved with benzyl alcohol is available in the following strength and package size:

When using a full dose heparin regimen, adjust the heparin sodium dose based on frequent blood coagulation tests. If the coagulation test is unduly prolonged or if hemorrhage occurs, discontinue heparin sodium promptly [see Overdosage (10)]. Periodic platelet counts and hematocrits are recommended during the entire course of heparin therapy, regardless of the route of administration [see Dosage and Administration (2.3)].

CAUTION: Certain glass syringes may malfunction, break or clog when connected to some Needleless Luer Access Devices (NLADs) and needles. This syringe has a larger internal syringe tip and an external collar (luer collar). The external collar must remain attached to the syringe. Data show that the syringe achieves acceptable connections with the BD Eclipse™ Needle and the Terumo SurGuard2™ Safety Needle and with the following non-center post NLADs: Alaris SMARTSITE™, B-Braun ULTRASITE™, BD-Q SYTE™, Maximum MAX PLUS™, and B-Braun SAFSITE™. The data also show acceptable connections are achieved to the center post ICU Medical CLAVE™. However, spontaneous disconnection of this glass syringe from needles and NLADs with leakage of drug product may occur. Assure that the needle or NLAD is securely attached before beginning the injection. Visually inspect the glass syringe-needle or glass syringe–NLAD connection before and during drug administration. Refer to Figure 1 for syringe diagram.

Figure 1

• Inspect the outer packaging (plastic tube) by verifying:

-plastic tube integrity

-drug name

-drug strength

-dose volume

-route of administration

-expiration date to be sure that the drug has not expired

-sterile field applicability

Do not use if package has been damaged.

2. Remove the plastic tube cap of the outer packaging to access the syringe.

3. Remove the syringe from the plastic tube.

4. Perform visual inspection on the syringe by verifying:

-absence of syringe damage

-absence of external particles

-absence of internal particles

-proper drug color

-expiration date to be sure that the drug has not expired

-drug name

-drug strength

-dose volume

-route of administration

-sterile field applicability

5. Push plunger rod slightly to break the stopper loose while tip cap is still on.

6. Remove tip cap by twisting it off. (See Figure 2 )

Figure 2

7. Discard the tip cap.

8. Expel air bubble.

9. Adjust dose by expelling extra volume (where applicable) from the syringe into sterile material prior to administration.

10. Connect the syringe to appropriate injection connection depending on route of administration. Before injection, ensure that the syringe is securely attached to the needle or needleless luer access device (NLAD).

11. Depress plunger rod to deliver medication. Ensure that pressure is maintained on the plunger rod during the entire administration.

12. Remove syringe from NLAD (if applicable) and discard into appropriate receptacle. To prevent needle-stick injuries, needles should not be recapped.

NOTES:

   -All steps must be done sequentially

   -Do not autoclave syringe

   -Do not use this product on a sterile field

-Do not introduce any other fluid into the syringe at any time

-This product is for single dose only; discard unused portion

Adjust the dosage of heparin sodium injection according to the patient's coagulation test results. Dosage is considered adequate when the activated partial thromboplastin time (aPTT) is 1.5 to 2 times normal or when the whole blood clotting time is elevated approximately 2.5 to 3 times the control value. When initiating treatment with heparin sodium injection by continuous intravenous infusion, determine the coagulation status (aPTT, INR, platelet count) at baseline and continue to follow aPTT approximately every 4 hours and then at appropriate intervals thereafter. When the drug is administered intermittently by intravenous injection, perform coagulation tests before each injection during the initiation of treatment and at appropriate intervals thereafter. After deep subcutaneous (intrafat) injections, tests for adequacy of dosage are best performed on samples drawn 4 to 6 hours after the injection.

Periodic platelet counts and hematocrits are recommended during the entire course of heparin therapy, regardless of the route of administration.

No long-term studies in animals have been performed to evaluate carcinogenic potential of heparin sodium. Also, no reproduction studies in animals have been performed concerning mutagenesis or impairment of fertility.

The most widely used dosage has been 5,000 units 2 hours before surgery and 5,000 units every 8 to 12 hours thereafter for 7 days or until the patient is fully ambulatory, whichever is longer. Administer the heparin sodium injection by deep subcutaneous (intrafat, i.e., above the iliac crest or abdominal fat layer, arm, or thigh) injection with a fine (25- to 27-gauge) needle to minimize tissue trauma.

For patients currently receiving intravenous heparin sodium, stop intravenous infusion of heparin sodium injection immediately after administering the first dose of oral anticoagulant; or for intermittent intravenous administration of heparin sodium injection, start oral anticoagulant 0 to 2 hours before the time that the next dose of heparin sodium injection was to have been administered.

The dosing recommendations in Table 1 are based on clinical experience. Although dosages must be adjusted for the individual patient according to the results of suitable laboratory tests, the following dosage schedules may be used as guidelines:

Serious and fatal adverse reactions including “gasping syndrome” can occur in neonates and infants treated with benzyl alcohol-preserved drugs, including heparin sodium injection vials. The “gasping syndrome” is characterized by central nervous system depression, metabolic acidosis, and gasping respirations.

When prescribing heparin sodium injection vials in infants consider the combined daily metabolic load of benzyl alcohol from all sources including heparin sodium injection vials (contains 10.42 mg of benzyl alcohol per mL) and other drugs containing benzyl alcohol. The minimum amount of benzyl alcohol at which toxicity may occur is not known [see Use in Specific Populations (8.4)].

Heparin-induced thrombocytopenia (HIT) is a serious antibody-mediated reaction. HIT occurs in patients treated with heparin sodium and is due to the development of antibodies to a platelet Factor 4-heparin complex that induce in vivo platelet aggregation. HIT may progress to the development of venous and arterial thromboses, a condition referred to as heparin-induced thrombocytopenia with thrombosis (HITT). Thrombotic events may also be the initial presentation for HITT. These serious thromboembolic events include deep vein thrombosis, pulmonary embolism, cerebral vein thrombosis, limb ischemia, stroke, myocardial infarction, mesenteric thrombosis, renal arterial thrombosis, skin necrosis, gangrene of the extremities that may lead to amputation, and possibly death. If the platelet count falls below 100,000/mm³ or if recurrent thrombosis develops, promptly discontinue heparin sodium, evaluate for HIT and HITT, and, if necessary, administer an alternative anticoagulant.

HIT or HITT can occur up to several weeks after the discontinuation of heparin therapy. Patients presenting with thrombocytopenia or thrombosis after discontinuation of heparin sodium should be evaluated for HIT or HITT.

Heparin can suppress adrenal secretion of aldosterone leading to hyperkalemia, particularly in patients with diabetes mellitus, chronic renal failure, pre-existing metabolic acidosis, a raised plasma potassium, or taking potassium sparing drugs. The risk of hyperkalemia appears to increase with duration of therapy but is usually reversible upon discontinuation of heparin.

Measure blood potassium in patients at risk of hyperkalemia before starting heparin therapy and periodically in all patients treated for more than 5 days or earlier as deemed fit by the clinician.

Store at 20° to 25°C (68° to 77°F). [See USP Controlled Room Temperature.]

Do not place syringe on a sterile field.

Discard unused portion.

Sterile, Nonpyrogenic.

The container closure is not made with natural rubber latex.

Principal Display Panel – Heparin Sodium Injection, USP 5,000 USP units per mL Syringe Label

For Intravenous or Subcutaneous Use

1 mL Prefilled Single-Dose Syringe

FROM PORCINE INTESTINAL MUCOSA

Mfd. For Meitheal Pharmaceuticals

NDC 71288-406-81

Rx Only

Heparin Sodium Injection, USP

5,000 USP units per mL

NOT for Lock Flush

Bleeding is the chief sign of heparin sodium overdosage.

Heparin is a heterogeneous group of straight-chain anionic mucopolysaccharides, called glycosaminoglycans, possessing anticoagulant properties. It is composed of polymers of alternating derivations of α-D-glucosamido (N-sulfated O-sulfated or N-acetylated) and O-sulfated uronic acid (α-L-iduronic acid or β-D-glucuronic acid).

Structure of heparin sodium (representative subunits):

Heparin Sodium Injection, USP is a sterile solution of heparin sodium derived from porcine intestinal mucosa, standardized for anticoagulant activity. It is to be administered by intravenous or deep subcutaneous routes. The potency is determined by a biological assay using a USP reference standard based on units of heparin activity per milligram.

Heparin Sodium Injection, USP preserved with benzyl alcohol, is available in the following concentrations per mL:

pH 5.0 to 7.5; sodium hydroxide and/or hydrochloric acid added, if needed, for pH adjustment.

Avoid using heparin sodium in the presence of major bleeding, except when the benefits of heparin therapy outweigh the potential risks.

Hemorrhage can occur at virtually any site in patients receiving heparin sodium. Fatal hemorrhages have occurred. Adrenal hemorrhage (with resultant acute adrenal insufficiency), ovarian hemorrhage, and retroperitoneal hemorrhage have occurred during anticoagulant therapy with heparin sodium [see Adverse Reactions (6.1)]. A higher incidence of bleeding has been reported in patients, particularly women, over 60 years of age [see Clinical Pharmacology (12.3)]. An unexplained fall in hematocrit, fall in blood pressure or any other unexplained symptom should lead to serious consideration of a hemorrhagic event.

Use heparin sodium with caution in disease states in which there is increased risk of hemorrhage, including:

• Cardiovascular - Subacute bacterial endocarditis, severe hypertension.
• Surgical - During and immediately following (a) spinal tap or spinal anesthesia or (b) major surgery, especially involving the brain, spinal cord, or eye.
• Hematologic - Conditions associated with increased bleeding tendencies, such as hemophilia, thrombocytopenia and some vascular purpuras.
• Patients with hereditary antithrombin III deficiency receiving concurrent antithrombin III therapy - The anticoagulant effect of heparin sodium is enhanced by concurrent treatment with antithrombin III (human) in patients with hereditary antithrombin III deficiency. To reduce the risk of bleeding, reduce the heparin sodium dose during concomitant treatment with antithrombin III (human).
• Gastrointestinal - Ulcerative lesions and continuous tube drainage of the stomach or small intestine.
• Other - Menstruation, liver disease with impaired hemostasis.

Do not use benzyl alcohol-preserved drugs in neonates and infants. Use preservative-free heparin sodium injection in neonates and infants [see Warnings and Precautions (5.4)].

There are no adequate and well controlled studies on heparin sodium use in pediatric patients. Pediatric dosing recommendations are based on clinical experience. In general, the following dosage schedule may be used as a guideline in pediatric patients:

There are no adequate and well controlled studies on heparin sodium use in pediatric patients. Pediatric dosing recommendations are based on clinical experience [see Dosage and Administration (2.5)].

Carefully examine all heparin sodium injection syringes to confirm choice of the correct strength prior to administration of the drug. Pediatric patients, including neonates, have died as a result of medication errors in which heparin sodium injection vials have been confused with “catheter lock flush” vials [see Warnings and Precautions (5.1)].

There are limited adequate and well-controlled studies in patients 65 years and older, however, a higher incidence of bleeding has been reported in patients, particularly women, over 60 years of age [see Warnings and Precautions (5.2)]. Patients over 60 years of age may require lower doses of heparin sodium.

Lower doses of heparin sodium may be indicated in these patients [see Clinical Pharmacology (12.3)].

The use of heparin sodium is contraindicated in patients with the following conditions:

• History of heparin-induced thrombocytopenia and heparin-induced thrombocytopenia and thrombosis [see Warnings and Precautions (5.3)];
• Known hypersensitivity to heparin sodium or pork products (e.g., anaphylactoid reactions) [see Adverse Reactions (6.1)];
• In whom suitable blood coagulation tests, e.g., the whole blood clotting time, partial thromboplastin time, etc., cannot be performed at appropriate intervals (this contraindication refers to full-dose heparin sodium; there is usually no need to monitor coagulation parameters in patients receiving low-dose heparin sodium);
• An uncontrolled active bleeding state [see Warnings and Precautions (5.2)], except when this is due to disseminated intravascular coagulation.

The following clinically significant adverse reactions are described elsewhere in the labeling:

• Hemorrhage [see Warnings and Precautions (5.2)]
• Heparin-Induced Thrombocytopenia and Heparin-Induced Thrombocytopenia and Thrombosis [see Warnings and Precautions (5.3)]
• Risk of Serious Adverse Reactions in Infants Due to Benzyl Alcohol Preservative [see Warnings and Precautions (5.4)]
• Thrombocytopenia [see Warnings and Precautions (5.5)]
• Heparin Resistance [see Warnings and Precautions (5.7)]
• Hypersensitivity [see Warnings and Precautions (5.8)]
• Hyperkalemia [see Warnings and Precautions (5.9)]

Drugs that interfere with platelet aggregation: May induce bleeding (7.2)

Thrombocytopenia in patients receiving heparin sodium has been reported at frequencies up to 30%. It can occur 2 to 20 days (average 5 to 9) following the onset of heparin therapy. Obtain platelet counts before and periodically during heparin therapy. Monitor thrombocytopenia of any degree closely. If the count falls below 100,000/mm³ or if recurrent thrombosis develops, promptly discontinue heparin sodium, evaluate for HIT and HITT, and, if necessary, administer an alternative anticoagulant [see Warnings and Precautions (5.3)].

Patients with documented hypersensitivity to heparin sodium should be given the drug only in clearly life-threatening situations.

Because heparin sodium injection is derived from animal tissue, it should be used with caution in patients with a history of allergy.

Various times (activated clotting time, activated partial thromboplastin time, prothrombin time, whole blood clotting time) are prolonged by full therapeutic doses of heparin sodium; in most cases, they are not measurably affected by low doses of heparin sodium. The bleeding time is usually unaffected by heparin sodium.

Absorption

Heparin sodium is not absorbed through the gastrointestinal tract and therefore administered via parenteral route. Peak plasma concentration and the onset of action are achieved immediately after intravenous administration.

Add 450 USP units to 600 USP units of heparin sodium per 100 mL of whole blood to prevent coagulation. Usually, 7,500 USP units of heparin sodium are added to 100 mL of 0.9% Sodium Chloride Injection, USP (or 75,000 USP units per 1,000 mL of 0.9% Sodium Chloride Injection, USP) and mixed; from this sterile solution, 6 mL to 8 mL are added per 100 mL of whole blood.

Resistance to heparin sodium is frequently encountered in fever, thrombosis, thrombophlebitis, infections with thrombosing tendencies, myocardial infarction, cancer, in postsurgical patients, and patients with antithrombin III deficiency. Close monitoring of coagulation tests is recommended in these cases. Adjustment of heparin sodium doses based on anti-Factor Xa levels may be warranted.

Digitalis, tetracyclines, nicotine or antihistamines may partially counteract the anticoagulant action of heparin sodium. Intravenous nitroglycerin administered to heparinized patients may result in a decrease of the partial thromboplastin time with subsequent rebound effect upon discontinuation of nitroglycerin. Careful monitoring of partial thromboplastin time and adjustment of heparin sodium dosage are recommended during coadministration of heparin sodium and intravenous nitroglycerin.

Antithrombin III (human) – The anticoagulant effect of heparin sodium is enhanced by concurrent treatment with antithrombin III (human) in patients with hereditary antithrombin III deficiency. To reduce the risk of bleeding, a reduced dosage of heparin sodium is recommended during treatment with antithrombin III (human).

Heparin Sodium Injection is indicated for:

• Prophylaxis and treatment of venous thrombosis and pulmonary embolism;
• Prevention of postoperative deep venous thrombosis and pulmonary embolism in patients undergoing major abdominothoracic surgery or who, for other reasons, are at risk of developing thromboembolic disease;
• Atrial fibrillation with embolization;
• Treatment of acute and chronic consumptive coagulopathies (disseminated intravascular coagulation);
• Prevention of clotting in arterial and cardiac surgery;
• Prophylaxis and treatment of peripheral arterial embolism.
• Anticoagulant use in blood transfusions, extracorporeal circulation, and dialysis procedures.

Heparin sodium may prolong the one-stage prothrombin time. Therefore, when heparin sodium is given with dicumarol or warfarin sodium, a period of at least 5 hours after the last intravenous dose or 24 hours after the last subcutaneous dose should elapse before blood is drawn, if a valid prothrombin time is to be obtained.

Drugs such as NSAIDS (including salicylic acid, ibuprofen, indomethacin, and celecoxib), dextran, phenylbutazone, thienopyridines, dipyridamole, hydroxychloroquine, glycoprotein IIb/IIIa antagonists (including abciximab, eptifibatide, and tirofiban), and others that interfere with platelet-aggregation reactions (the main hemostatic defense of heparinized patients) may induce bleeding and should be used with caution in patients receiving heparin sodium. To reduce the risk of bleeding, a reduction in the dose of antiplatelet agent or heparin sodium is recommended.

Heparin sodium interacts with the naturally occurring plasma protein, Antithrombin III, to induce a conformational change, which markedly enhances the serine protease activity of Antithrombin III, thereby inhibiting the activated coagulation factors involved in the clotting sequence, particularly Xa and IIa. Small amounts of heparin sodium inhibit Factor Xa, and larger amounts inhibit thrombin (Factor IIa). Heparin sodium also prevents the formation of a stable fibrin clot by inhibiting the activation of the fibrin stabilizing factor. Heparin sodium does not have fibrinolytic activity; therefore, it will not lyse existing clots.

Patients undergoing total body perfusion for open-heart surgery should receive an initial dose of not less than 150 units of heparin sodium per kilogram of body weight. Frequently, a dose of 300 units per kilogram is used for procedures estimated to last less than 60 minutes, or 400 units per kilogram for those estimated to last longer than 60 minutes.

To ensure continuous anticoagulation when converting from heparin sodium injection to warfarin, continue full heparin therapy for several days until the INR (prothrombin time) has reached a stable therapeutic range. Heparin therapy may then be discontinued without tapering [see Drug Interactions (7.1)].

• Fatal Medication Errors: Confirm choice of correct strength prior to administration (5.1)
• Hemorrhage: Fatal cases have occurred. Use caution in conditions with increased risk of hemorrhage (5.2)
• HIT and HITT: Monitor for signs and symptoms and discontinue if indicative of HIT and HITT (5.3)
• Benzyl Alcohol Toxicity: Do not use benzyl alcohol-preserved drugs in neonates and infants. (5.4)
• Monitoring: Blood coagulation tests guide therapy for full-dose heparin sodium.
• Monitor platelet count and hematocrit in all patients receiving heparin sodium (5.5, 5.6)
• Hyperkalemia: Measure blood potassium in patients at risk of hyperkalemia before starting heparin therapy and periodically in all patients (5.9)

Recommended Adult Dosages:

• Therapeutic Anticoagulant Effect with Full-Dose Heparin Sodium^† (2.4)

Do not use heparin sodium injection as a “catheter lock flush” product. Heparin sodium injection is supplied in syringes containing 5,000 units in 1 mL. Fatal hemorrhages have occurred in pediatric patients due to medication errors in which 1 mL heparin sodium injection vials were confused with 1 mL “catheter lock flush” vials. Carefully examine all heparin sodium injection syringes to confirm the correct syringe choice prior to administration of the drug.

Follow equipment manufacturers' operating directions carefully. A dose of 25 units/kg to 30 units/kg followed by an infusion rate of 1,500 units/hour to 2,000 units/hour is suggested based on pharmacodynamic data if specific manufacturers' recommendations are not available.

Heparin Sodium Injection, USP is available as 5,000 USP units in a 1 mL prefilled single-dose syringe, preserved with benzyl alcohol.

The following adverse reactions have been identified during post approval use of heparin sodium injection. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

• Hemorrhage is the chief complication that may result from heparin therapy [see Warnings and Precautions (5.2)]. Gastrointestinal or urinary tract bleeding during anticoagulant therapy may indicate the presence of an underlying occult lesion. Bleeding can occur at any site but certain specific hemorrhagic complications may be difficult to detect:
  • Adrenal hemorrhage, with resultant acute adrenal insufficiency, has occurred with heparin therapy, including fatal cases.
  • Ovarian (corpus luteum) hemorrhage developed in a number of women of reproductive age receiving short- or long-term heparin therapy.
  • Retroperitoneal hemorrhage
• HIT and HITT, including delayed onset cases [see Warnings and Precautions (5.3)].
• Local Irritation – Local irritation, erythema, mild pain, hematoma or ulceration may follow deep subcutaneous (intrafat) injection of heparin sodium. Because these complications are much more common after intramuscular use, the intramuscular route is not recommended.
• Histamine-like reactions – Such reactions have been observed at the site of injections. Necrosis of the skin has been reported at the site of subcutaneous injection of heparin sodium, occasionally requiring skin grafting [see Warnings and Precautions (5.3)].
• Hypersensitivity – Generalized hypersensitivity reactions have been reported, with chills, fever and urticaria as the most usual manifestations, and asthma, rhinitis, lacrimation, headache, nausea and vomiting, and anaphylactoid reactions, including shock, occurring less frequently. Itching and burning, especially on the plantar side of the feet, may occur [see Warnings and Precautions (5.8)].
• Elevations of aminotransferases – Significant elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels have occurred in patients who have received heparin sodium.
• Miscellaneous - Osteoporosis following long-term administration of high doses of heparin sodium, cutaneous necrosis after systemic administration, suppression of aldosterone synthesis, delayed transient alopecia, priapism, and rebound hyperlipemia on discontinuation of heparin sodium have also been reported.
• Metabolism and Nutrition Disorders – Hyperkalemia.

• Pregnancy: Preservative-free formulation recommended. Limited human data in pregnant women. (8.1)
• Lactation: Advise females not to breastfeed. (8.2)
• Pediatric Use: Use preservative-free formulation in neonates and infants. (8.4)
• Geriatric Use: A higher incidence of bleeding reported in patients, particularly women, over 60 years of age. (8.5)

Confirm the choice of the correct heparin sodium injection syringe to ensure that the 1 mL syringe is not confused with a “catheter lock flush” syringe or other 1 mL syringe of incorrect strength [see Warnings and Precautions (5.1)]. Confirm the selection of the correct formulation and strength prior to administration of the drug.

To lessen this risk, the 1 mL syringe includes a red cautionary statement. Read the cautionary statement and confirm that you have selected the correct medication and strength.

When heparin sodium injection is added to an infusion solution for continuous intravenous administration, invert the container repeatedly to ensure adequate mixing and prevent pooling of the heparin sodium in the solution.

Inspect parenteral drug products visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Use only if solution is clear and the seal is intact. Do not use if solution is discolored or contains a precipitate.

Administer heparin sodium injection by intermittent intravenous injection, intravenous infusion, or deep subcutaneous (intrafat, i.e., above the iliac crest or abdominal fat layer) injection. Do not administer heparin sodium injection by intramuscular injection because of the risk of hematoma at the injection site [see Adverse Reactions (6)].

Heparin Sodium Injection, USP preserved with benzyl alcohol is available in the following strength and package size:

When using a full dose heparin regimen, adjust the heparin sodium dose based on frequent blood coagulation tests. If the coagulation test is unduly prolonged or if hemorrhage occurs, discontinue heparin sodium promptly [see Overdosage (10)]. Periodic platelet counts and hematocrits are recommended during the entire course of heparin therapy, regardless of the route of administration [see Dosage and Administration (2.3)].

CAUTION: Certain glass syringes may malfunction, break or clog when connected to some Needleless Luer Access Devices (NLADs) and needles. This syringe has a larger internal syringe tip and an external collar (luer collar). The external collar must remain attached to the syringe. Data show that the syringe achieves acceptable connections with the BD Eclipse™ Needle and the Terumo SurGuard2™ Safety Needle and with the following non-center post NLADs: Alaris SMARTSITE™, B-Braun ULTRASITE™, BD-Q SYTE™, Maximum MAX PLUS™, and B-Braun SAFSITE™. The data also show acceptable connections are achieved to the center post ICU Medical CLAVE™. However, spontaneous disconnection of this glass syringe from needles and NLADs with leakage of drug product may occur. Assure that the needle or NLAD is securely attached before beginning the injection. Visually inspect the glass syringe-needle or glass syringe–NLAD connection before and during drug administration. Refer to Figure 1 for syringe diagram.

Figure 1

• Inspect the outer packaging (plastic tube) by verifying:

-plastic tube integrity

-drug name

-drug strength

-dose volume

-route of administration

-expiration date to be sure that the drug has not expired

-sterile field applicability

Do not use if package has been damaged.

2. Remove the plastic tube cap of the outer packaging to access the syringe.

3. Remove the syringe from the plastic tube.

4. Perform visual inspection on the syringe by verifying:

-absence of syringe damage

-absence of external particles

-absence of internal particles

-proper drug color

-expiration date to be sure that the drug has not expired

-drug name

-drug strength

-dose volume

-route of administration

-sterile field applicability

5. Push plunger rod slightly to break the stopper loose while tip cap is still on.

6. Remove tip cap by twisting it off. (See Figure 2 )

Figure 2

7. Discard the tip cap.

8. Expel air bubble.

9. Adjust dose by expelling extra volume (where applicable) from the syringe into sterile material prior to administration.

10. Connect the syringe to appropriate injection connection depending on route of administration. Before injection, ensure that the syringe is securely attached to the needle or needleless luer access device (NLAD).

11. Depress plunger rod to deliver medication. Ensure that pressure is maintained on the plunger rod during the entire administration.

12. Remove syringe from NLAD (if applicable) and discard into appropriate receptacle. To prevent needle-stick injuries, needles should not be recapped.

NOTES:

   -All steps must be done sequentially

   -Do not autoclave syringe

   -Do not use this product on a sterile field

-Do not introduce any other fluid into the syringe at any time

-This product is for single dose only; discard unused portion

Adjust the dosage of heparin sodium injection according to the patient's coagulation test results. Dosage is considered adequate when the activated partial thromboplastin time (aPTT) is 1.5 to 2 times normal or when the whole blood clotting time is elevated approximately 2.5 to 3 times the control value. When initiating treatment with heparin sodium injection by continuous intravenous infusion, determine the coagulation status (aPTT, INR, platelet count) at baseline and continue to follow aPTT approximately every 4 hours and then at appropriate intervals thereafter. When the drug is administered intermittently by intravenous injection, perform coagulation tests before each injection during the initiation of treatment and at appropriate intervals thereafter. After deep subcutaneous (intrafat) injections, tests for adequacy of dosage are best performed on samples drawn 4 to 6 hours after the injection.

Periodic platelet counts and hematocrits are recommended during the entire course of heparin therapy, regardless of the route of administration.

No long-term studies in animals have been performed to evaluate carcinogenic potential of heparin sodium. Also, no reproduction studies in animals have been performed concerning mutagenesis or impairment of fertility.

The most widely used dosage has been 5,000 units 2 hours before surgery and 5,000 units every 8 to 12 hours thereafter for 7 days or until the patient is fully ambulatory, whichever is longer. Administer the heparin sodium injection by deep subcutaneous (intrafat, i.e., above the iliac crest or abdominal fat layer, arm, or thigh) injection with a fine (25- to 27-gauge) needle to minimize tissue trauma.

For patients currently receiving intravenous heparin sodium, stop intravenous infusion of heparin sodium injection immediately after administering the first dose of oral anticoagulant; or for intermittent intravenous administration of heparin sodium injection, start oral anticoagulant 0 to 2 hours before the time that the next dose of heparin sodium injection was to have been administered.

The dosing recommendations in Table 1 are based on clinical experience. Although dosages must be adjusted for the individual patient according to the results of suitable laboratory tests, the following dosage schedules may be used as guidelines:

Serious and fatal adverse reactions including “gasping syndrome” can occur in neonates and infants treated with benzyl alcohol-preserved drugs, including heparin sodium injection vials. The “gasping syndrome” is characterized by central nervous system depression, metabolic acidosis, and gasping respirations.

When prescribing heparin sodium injection vials in infants consider the combined daily metabolic load of benzyl alcohol from all sources including heparin sodium injection vials (contains 10.42 mg of benzyl alcohol per mL) and other drugs containing benzyl alcohol. The minimum amount of benzyl alcohol at which toxicity may occur is not known [see Use in Specific Populations (8.4)].

Heparin-induced thrombocytopenia (HIT) is a serious antibody-mediated reaction. HIT occurs in patients treated with heparin sodium and is due to the development of antibodies to a platelet Factor 4-heparin complex that induce in vivo platelet aggregation. HIT may progress to the development of venous and arterial thromboses, a condition referred to as heparin-induced thrombocytopenia with thrombosis (HITT). Thrombotic events may also be the initial presentation for HITT. These serious thromboembolic events include deep vein thrombosis, pulmonary embolism, cerebral vein thrombosis, limb ischemia, stroke, myocardial infarction, mesenteric thrombosis, renal arterial thrombosis, skin necrosis, gangrene of the extremities that may lead to amputation, and possibly death. If the platelet count falls below 100,000/mm³ or if recurrent thrombosis develops, promptly discontinue heparin sodium, evaluate for HIT and HITT, and, if necessary, administer an alternative anticoagulant.

HIT or HITT can occur up to several weeks after the discontinuation of heparin therapy. Patients presenting with thrombocytopenia or thrombosis after discontinuation of heparin sodium should be evaluated for HIT or HITT.