Dalteparin (Fragmin) is a low-molecular-weight heparin that is used in the prophylaxis and treatment of patients with deep vein thrombosis and pulmonary embolism.

Dalteparin (Fragmin) Uses:

• Anticoagulant for hemodialysis and hemofiltration (Fragmin [Canadian product only]):

  • To prevent clot formation in the extracorporeal system during hemodialysis and hemofiltration in connection with AKI or CKD

• Non-ST elevation acute coronary syndromes:

  • To prevent complications related to ischemia in patients with unstable angina or non-Q-wave myocardial infarction on concurrent aspirin therapy.

• Venous thromboembolism prophylaxis:

  • To prevent the occurrence of DVT which may lead to pulmonary embolism in a wide range of patients. Few examples include:
    • Patients undergoing abdominal surgery who are at risk for thromboembolism complications (like age>40 years, obesity, malignancy, history of DVT or PE, surgical procedures requiring general anesthesia lasting >30 minutes)
    • Patients undergoing total hip arthroplasty
    • Severe immobility during an acute illness imposing an increased risk of DVT/PE

• Venous thromboembolism treatment in patients with active cancer:

  • Used for extended treatment (i.e 6 months) of acute symptomatic VTE (ie, DVT and/or PE) to reduce the recurrence of VTE in patients with active malignancy.

Note: In cancer patients suffering from VTE (ie, DVT and/or PE), according to ACCP guidelines low molecular weight heparin (LMWH) should be preferred over oral anticoagulants for initial and long-term treatment.

• Off Label Use of Dalteparin in Adults:

  • Acute symptomatic thrombosis of superficial vein (lower extremity; ≥5 cm in length)
  • DVT and/or PE treatment
  • Mechanical heart valve (bridging anticoagulation)
  • Treatment of Venous thromboembolism in pregnancy
  • Prophylaxis for Venous thromboembolism like in total knee arthroplasty (TKA)

Dalteparin (Fragmin) Dose in Adults

Dalteparin (Fragmin) Dose in the treatment of Acute symptomatic superficial vein thrombosis of the lower extremities ≥5 cm in length) (off label):

• Subcutaneous: 5,000 units twice daily for 45 days

Note: If anticoagulation is discontinued earlier than 45 days there is a high risk of recurrence. D-dimer should be monitored at baseline and again at 45 days; a longer course ma needed if the d-dimer remains elevated.

Dalteparin (Fragmin) Dose in the treatment of Anticoagulant for hemodialysis and hemofiltration (off-label): IV: (Fragmin Canadian product labeling):

• Chronic renal failure with no other bleeding risks:

  • Hemodialysis/filtration ≤4 hours:

    • IV bolus: 5,000 units; dose may be adjusted during subsequent dialysis sessions in increments of 500 to 1,000 anti-Xa units depending on the outcome of the previous dialysis session.
    • An alternate method is to administer an IV bolus of 30 to 40 units/kg, followed by an infusion of 10 to 15 units/kg/hour.
    • Note: Plasma concentrations of 0.5 to 1 units anti-Xa/mL can be achieved by both methods.

  • Hemodialysis/filtration >4 hours:

    • IV bolus: 30 to 40 units/kg, followed by an infusion of 10 to 15 units/kg/hour (plasma concentration of 0.5 to 1 units antiXa/mL is typically produceed)

• Acute renal failure and high bleeding risk:

  • IV bolus: 5 to 10 units/kg, followed by an infusion of 4 to 5 units/kg/hour (plasma concentrations of 0.2 to 0.4 units anti Xa/mL is typically produceed)

Dalteparin (Fragmin) Dose in the treatment of Mechanical heart valve (bridging anticoagulation) (off-label):

Note: May consider bridging during periprocedural intervals of subtherapeutic anticoagulation when there is an additional risk factor for thromboembolism like atrial fibrillation, left ventricular systolic dysfunction, older-generation mechanical valves, or mechanical mitral or tricuspid valve replacement. Bridging may not be required in individuals who have undergone an aortic valve replacement but do not have additional risk factors for thrombosis (other than the mechanical valve). For this indication, it is also reasonable to use dalteparin, during pregnancy, especially during the first trimester.

• Subcutaneous: 100 units/kg/dose twice a day; dose should be adjusted based on anti-Xa monitoring.

Dalteparin (Fragmin) Dose in the treatment of Non-ST elevation acute coronary syndromes: For medical management when an invasive approach is not planned:

• Subcutaneous:: 120 units/kg (maximum dose: 10,000 units) twice a day with concomitant aspirin therapy; should be continued until the patient is clinically stable (the usual duration of therapy is 5 to 8 days).

Dalteparin (Fragmin) Dose in the VTE prophylaxis:

Note: For patients assessed to be at the highest risk (eg, Caprini score >8, stroke, active cancer, multiple risk factors), many experts combine pharmacologic and mechanical methods or increase the frequency of the dose frequency to two times a day (eg, 5,000 units twice daily). Always consider the risk of bleeding while increasing the dose.

• Hospitalized medical patients with acute illness at moderate and high risk for VTE (including patients with active cancer):

  • Subcutaneous: 5,000 units once in 24 hours; should be continued during the hospital stay or until the patient becomes fully mobile and the risk of VTE diminishes.

Note: Extended prophylactic dose after the acute hospital stay is not routinely recommended.

Dalteparin (Fragmin) Dose in the treatment of Major non-orthopedic surgery (patients with active cancer) (off-label):

Note: Different regimens are available and include the following:

• Subcutaneous: 5,000 units started 10 to 12 hours prior to surgery and 5,000 units once in 24 hours thereafter, OR
• Subcutaneous: 2,500 units started 2 to 4 hours prior to surgery and 5,000 units once per 24 hours thereafter, OR
• Subcutaneous: 5,000 units once per 24 hours started ~6 to 12 hours post-surgery

Note: The optimal duration of prophylaxis is yet to be established. Give for a minimum of 7 to 10 days. In those undergoing major abdominal or pelvic surgery, extending treatment for up to 4 weeks may be reasonable.

Dalteparin (Fragmin) Dose in the treatment of Nonorthopedic surgery (patients without cancer):

• For patients with moderate and high risk of VTE and low risk of bleeding:

  • Subcutaneous: 5,000 units ~12 hours prior to surgery (or the evening prior to surgery) and then 5,000 units per 24 hours thereafter is recommended.
  • Alternatively,  pharmacologic prophylaxis can be postponed until after surgery (eg, high bleeding risk) when it is safe to be started. If achieving hemostasis is difficult postoperatively, prophylaxis should be withheld until it is safe to reinitiate. Should be continued until completely mobile and risk of VTE diminishes (typically up to 10 days).
  • Manufacturer’s labeling: The current clinical practice may not be reflected by the dosing in the prescribing information. In low and moderate risk patients:
  • Subcutaneous: 2,500 units 1 to 2 hours before surgery, then 2,500 units per 24 hours thereafter.

Dalteparin (Fragmin) Dose in Pregnancy (off-label):

Note: When the risk of VTE is moderate and high during antepartum and postpartum periods. The dose varies according to the individual based on risks of thrombosis and bleeding complications.

• Prophylactic dose:

  • Subcutaneous: 5,000 units once daily

• Intermediate dose:

  • Subcutaneous: 5,000 units twice a day; however, an alternative intermediate regimen of 5,000 units once a day may be used by some of the experts, increasing as pregnancy progresses to 100 units/kg per 24 hours.

• Adjusted dose (therapeutic):

  • Subcutaneous: 100 units/kg twice daily; or 200 units/kg per 24 hours reserved for patients at the highest risk (eg, history of recurrent thrombosis or severe thrombophilia)

Note:

• Anticoagulation management prior to delivery varies according to every individual.
• Options include replacing with unfractionated heparin at ~36 to 37 weeks gestation or extending to 38 to 39 weeks gestation in patients having a very low risk of delivery while on dalteparin.
• In such patients, dalteparin should be discontinued ≥12 hours before delivery when prophylactic doses are being given or ≥24 hours before delivery when higher doses are being given, particularly if the patient is planned for neuraxial anesthesia; the dose may be restarted ≥4 to 6 hours after vaginal delivery or ≥6 to 12 hours after c-section unless significant bleeding has occurred.
• Continue anticoagulation for up to 6 weeks postpartum in women at high risk.

Dalteparin (Fragmin) Dose in the treatment of Total hip arthroplasty (THA) or total knee arthroplasty (TKA) (TKA is an off-label):

• SubQ: 5,000 units per 24 hours, with initial dose administered ≥12 hours preoperatively or ≥12 hours postoperatively after achieving hemostasis; other regimens include 2,500 units pre- or postoperatively with a maintenance dosage of 5,000 units per 24 hours.
• Optimal duration of prophylaxis is not known, but usually, its is given for a minimum of 10 to 14 days. Can extend the prophylaxis beyond the minimum 10 to 14 days for up to 35 days; may be discontinued earlier if completely mobile; a duration at the higher end of range (eg, 30 days) is suggested by some experts for THA and at the lower end of range (eg, 10 to 14 days) for TKA.

Dalteparin (Fragmin) Dose in the VTE treatment:

Note: For timing of initiating oral anticoagulants, see Transitioning between anticoagulants. For patients with active cancer, see VTE treatment in patients with active cancer.

• DVT and/or PE (off-label use):

  • Inpatient treatment: Subcutaneous: 200 units/kg per 24 hours or 100 units/kg every 12 hourly. Note: Outpatient treatment may be considered in selective low-risk patients for the remainder of the course after the first dose has been administered in a hospital or urgent care center.
• Duration of therapeutic anticoagulation (first episode, general recommendations):
  • The optimal duration of therapy is not known and is determined by many factors like whether the event was provoked or unprovoked, patient risk factors for recurrence and bleeding, and individual preference.

• Provoked VTE:

  • 3 months (provided the provoking risk factor is no longer present)

• Unprovoked PE or DVT (proximal or isolated distal):

  • ≥3 months depending on the risk of VTE recurrence and bleeding

Note: Periodically reassess all patients receiving indefinite therapeutic anticoagulation with no specified stop date.

Dalteparin (Fragmin) Dose in the VTE treatment in patients with active cancer: SubQ:

• Initial (month 1): 200 units/kg (maximum dose: 18,000 units) once daily for 1 month, followed by maintenance therapy during months two to six
• Maintenance (months 2 to 6): 150 units/kg (maximum dose: 18,000 units) per 24 hours. Alternatively, may use warfarin for maintenance therapy; however, meta-analyses and randomized control trials have validated that LMWH is superior to warfarin. While using warfarin for maintenance therapy, dalteparin should be overlapped with warfarin for a minimum of 5 to 7 days and continued until INR comes in the therapeutic range for at least 2 days.
• Maintenance beyond 6 months (off-label): ACCP and ASCO guidelines for VTE prophylaxis/treatment have recommended that anticoagulation should be continued beyond 6 months in selected patients due to the persistent high risk of recurrence in those with active cancer; risk vs benefit of bleeding and recurrence should be considered.

• Dosage adjustment for thrombocytopenia:

  • If the platelet count is between 50,000 to 100,000/mm³, the daily dose should be reduced by 2,500 units for patients weighing 46 to 82 kg and by 3,000 units for patients weighing ≥83 kg until platelet count improves to ≥100,000/mm³. If platelet count <50,000/mm³, dalteparin use should be discontinued until platelet count recovers to >50,000/mm³.

Dalteparin (Fragmin) Dose in the VTE treatment in pregnancy (off-label) :

• Subcutaneous: 200 units/kg/dose per 24 hours or 100 units/kg/dose twice daily. According to some experts, anti-Xa levels should be monitored for dose adjustment.

Note: Anticoagulation management prior to delivery varies according to every individual. Options include replacing with unfractionated heparin at ~36 to 37 weeks gestation or extending to 38 to 39 weeks gestation in patients having a very low risk of delivery while on dalteparin. In such patients, dalteparin should be discontinued ≥12 hours before delivery when prophylactic doses are being given or ≥24 hours before delivery when higher doses are being given, particularly if the patient is planned for neuraxial anesthesia; the dose may be restarted ≥4 to 6 hours after vaginal delivery or ≥6 to 12 hours after c-section unless significant bleeding has occurred. Continue anticoagulation for up to 6 weeks postpartum in women at high risk.

Transitioning between anticoagulants:

Note: This provides general guidance on transitioning between anticoagulants; for additional details also refer to the local protocol:

• Transitioning from another anticoagulant to dalteparin:

  • Transitioning from therapeutic IV UFH infusion to therapeutic-dose dalteparin:
    • UFH should be discontinued and dalteparin should be started within 1 hour.
    • Note: Local protocols should be consulted if aPTT is not in the therapeutic range at the time UFH is discontinued.

• Transitioning from dalteparin to another anticoagulant:

  • Transitioning from therapeutic-dose dalteparin to therapeutic IV UFH infusion:
    • IV UFH (rate based on indication) should be started 1 to 2 hours before the next dose of dalteparin would have been due. Note: Omit the loading dose of IV UFH.
  • Transitioning from prophylactic dalteparin to therapeutic IV UFH:
    • Start UFH without delay. Use a UFH bolus/loading dose if indicated.
  • Transitioning from therapeutic-dose dalteparin to warfarin for VTE treatment:
    • Warfarin should be started on the 1st or 2nd day of treatment and overlap with dalteparin until INR is ≥2 for at least 2 measurements 1 day apart (duration of overlap is usually 4 to 5 days).
  • Transitioning from therapeutic-dose dalteparin to warfarin for nonvalvular atrial fibrillation:
    • In the absence of a high risk of immediate thromboembolism, warfarin can be started without parenteral anticoagulant (ie, no bridging). In presence of a high risk of immediate thromboembolism, bridging should be considered i.e overlapping with dalteparin until INR is within the therapeutic range.
  • Transitioning from therapeutic-dose dalteparin to a direct oral anticoagulant (DOAC):
    • Note: Some DOACs (dabigatran, edoxaban) require 5 days of parenteral anticoagulation before transitioning in the treatment of VTE.

• General transition recommendation:

  • DOAC should be started within 2 hours prior to the next scheduled dose of dalteparin.
• VTE initial treatment transition (alternative recommendation):
  • For acute VTE, some experts may begin DOAC within 6 to 12 hours after the last dose of every 12 hourly LMWH regimen or within 12 to 24 hours after every 24 hourly LMWH regimen.

Dalteparin (Fragmin) Dose in Childrens

Note:

• Every 2,500 units of anti-Xa activity is equal to 16 mg of dalteparin (World Health Organization First International Low Molecular Weight Heparin Reference Standard).
• In a pediatric thrombosis treatment trial, doses were rounded to the nearest 100 units and in obese patients, doses were based on lean body weight.

Dalteparin (Fragmin) Dose in the Prophylaxis:

• Infants, Children, and Adolescents:

  • SubQ: 100 units/kg/dose once daily; dose should be titrated to anti-Xa levels: 0.2 to 0.4 units/mL (sample should be drawn 4 hours after a dose); maximum dose: 5,000 units/dose.

Dalteparin (Fragmin) Dose in the treatment of Thrombosis:

• Initial:
  • Infants: SubQ: 150 units/kg/dose twice daily
  • Children: SubQ: 125 units/kg/dose twice daily
  • Adolescents: SubQ: 100 units/kg/dose twice daily

Dosing adjustment:

• The dose should be titrated to achieve a 4-hour postdose target anti-Xa level 0.5 to 1 units/mL; in trials, evaluation of anti-Xa levels was most commonly done after the 3rd dose, but levels after the first and second doses were also used; dose adjustments were made in 10% to 20% increments in one trial.

Pregnancy Risk Category: C

• The risk of fetal bleeding and teratogenic effects are not increased by Low molecular weight heparin.
• Unfractionated heparin is preferred during pregnancy for acute VTE treatment.
• LMWH can also be used prophylactically in pregnant women at high risk. Stop using LMWH for at least 24 hours before induction of labor, or a scheduled c-section.
• Women who have had a cesarean section may be eligible for prophylactic LMWH.
• Women on long-term anticoagulation with Warfarin should undergo LMWH substitution before they are allowed to conceive.
• These are some things to consider when selecting therapy.
  • The Fetal Outcomes, i.e. pregnancy loss or malformations
  • Maternal outcomes, ie VTE, hemorhage
  • Therapy burden
  • Preference for the mother.
• Women with mechanical heart valves may also be able to use LMWH.
• Multiple-dose vials contain benzyl alcohol.
• Pregnant women should avoid using them due to the possibility of developing the gasping syndrome in infants. The preservative-free formulation is best.

Use during breastfeeding:

• Breast milk from women who received prophylactic doses dalteparin was positive for anti-Xa activity.
• Low molecular weight heparin has low absorption when administered orally.
• According to the manufacturer, there are some things you should consider when deciding whether or not to breastfeed during therapy.
  • The risk of infant exposure
  • Breastfeeding is good for the infant
  • Benefits of mother-to-child treatment
• According to the available guidelines, continue LMWH for breastfeeding women.

Dose in Kidney disease:

• No dosage adjustments provided in the manufacturer's labeling.
• LMWHs use in renal impairment (especially severe renal impairment [CrCl <30 mL/minute]) has been shown to result in enhanced anti-Xa activity and increased bleeding risk.
• However, no accumulation was noted in critically ill patients with severe renal insufficiency (CrCl <30 mL/minute) getting prophylactic doses (5,000 units/day) for a median of 7 days.
• The manufacturer has recommended monitoring anti-Xa levels in cancer patients (if CrCl <30 mL/minute) receiving treatment for venous thromboembolism to determine the appropriate dose.

Hemodialysis:

• Not dialyzable

Dose in Liver disease:

No dosage adjustments provided in the manufacturer's labeling. Use cautiously severe hepatic impairment; repeated dosing may result in drug accumulation and increased risk for bleeding.

Note: As with all anticoagulants, the major adverse effect of dalteparin is bleeding. Hemorrhage may occur at virtually any site. Multiple factors determine the risk.

Common Side Effects of Dalteparin (Fragmin):

• Hematologic & oncologic:

  • Hemorrhage
  • Thrombocytopenia including
    • heparin-induced thrombocytopenia

Less Common Side Effects of Dalteparin (Fragmin):

• Hematologic & oncologic:

  • Major hemorrhage
  • Wound hematoma

• Hepatic:

  • Increased serum ALT
  • Increased serum AST

• Local:

  • Pain at the injection site
  • Hematoma at the injection site

Contraindications to Dalteparin (Fragmin):

• Hypersensitivity to dalteparin (eg: pruritus and rash, anaphylactic reaction), heparin or pork products, or any other component of the formulation
• Previous history of HIT (heparin-induced hemoglobinemia) or HIT with thrombosis
• Active major bleeding
• Patients suffering from unstable angina
• Non-Q-wave MI
• Epidural/neuraxial anesthesia for prolonged venous embolism prophylaxis

  Notice:

• Patients with HIT are not advised to use Dalteparin.
• This is because of the high cross-reactivity with the heparin-platelet-factor-4 antibody.

Canadian labeling: Additional contraindications not in US labeling

• Hypersensitivity to LMWHs
• Patients with a history of HIT (or suspected HIT) and/or patients who have had an in vitro platelet-aggregation testing in the presence dalteparin positive
• Septic endocarditis (endocarditis acute, subacute or lenta)
• Major blood clotting disorders
• Acute gastroduodenal ulcer
• Cerebral hemorhage
• Hypertension uncontrolled and severe
• Retinopathy (Diabetic or hemorhagic).
• Hemorrhage risk factors that may be present in certain conditions
• Operation and injuries to the CNS, eyes, ears, and CNS.

Warnings and precautions

• Bleeding

  • Any site may cause bleeding.
  • Closely monitor for bleeding.
  • Patients at higher risk of bleeding should exercise extreme caution.
  • There are several risk factors for bleeding: bacterial endocarditis, congenital and acquired bleeding disorders, active ulcerative or angiodysplastic GI disease; severe uncontrolled hypertension; hemorhagic stroke; use soon after brain, spine, or ophthalmology surgeries; patients who have been treated with other drugs that can cause bleeding (eg platelet inhibitors, SSRIs); recent GI bleeding, ulceration; qualitative, quantitative platelet defects; hypertensive retinopathy or diabetic retinopathy
  • If a patient has bleeding, the medication should be stopped
  • Contraindication: Active major bleeding. Protamine may be considered as partial reversal in cases of overdose (consult the Protamine monograph to learn more about dosing recommendations).

• Hyperkalemia:

  • Monitor potassium levels
  • Hyperkalemia could be caused by a reduction in aldosterone levels.
  • Patients with hyperkalemia are more likely to experience it.

• Thrombocytopenia:

  • This may cause thrombocytopenia, including thrombocytopenia and thrombosis. Pay attention to your platelet count.
  • Contraindication: HIT and HIT with thrombosis are not recommended.
  • Patients with platelet counts below 100,000/mm3 or patients who have developed thrombosis due to the induction of dalteparin should be stopped immediately.
  • Avoid contact with platelet defect or congenital thrombocytopenia.

• GI ulceration

  • Be careful.

• Hepatic impairment

  • Be careful. Severe hepatic dysfunction can increase the risk of bleeding.

• Renal impairment

  • Be careful. Risiko of bleeding with severe renal impairment (CrCl 30mL/minute)

Monitoring Parameters:

• Platelet count
• hemoglobin
• hematocrit
• fecal occult blood
• signs and symptoms of bleeding
• Anti-Xa levels (as appropriate)
• serum creatinine at baseline and during therapy
• PT and/or aPTT monitoring is not necessary.
• Routine monitoring is not required for anti-Xa activity but has been utilized in patients with obesity and/or renal insufficiency.
• Anti-Xa activity can appropriately measure the therapeutic effect but poorly predicts hemorrhagic risk.
• For patients >190 kg, if anti-Xa monitoring is available, it is recommended to adjust dose based on anti-Xa levels; if there is a lack of availability of anti-Xa monitoring, the dose should be reduced if bleeding occurs.
• Obese patients should be monitored closely for signs/symptoms of thromboembolism.
• It is recommended to monitor anti-Xa levels in pregnant women receiving therapeutic doses of dalteparin or when dalteparin is being given for the prevention of thromboembolism with mechanical heart valves.

How to administer Dalteparin?

Subcutaneous:

• Administer as a deep subcutaneous injection; IM injection should not be given.
• May inject in a U-shape pattern around the umbilicus, the upper outer quadrant of the thigh, or the upper outer quadrangle of the buttock.
• Use thumb and forefinger should be used for lifting up a fold of skin when injecting in the umbilical area or thigh.
• The entire needle length should be injected at a 45- to 90-degree angle.
• The air bubble should not be expelled from the prefilled syringe prior to injection.
• May expel the air bubble (and extra solution, if applicable) from graduated syringes.
• In order to minimize bruising, the injection site should not be rubbed. Daily rotate injection sites.

For conversion of IV unfractionated heparin (UFH) infusion to SubQ dalteparin:

• The specific dose for dalteparin based on indication should be calculated after discontinuation of UFH and dalteparin should be started within 1 hour.

For conversion of subcutaneous dalteparin to IV UFH infusion:

• Dalteparin should be stopped; a specific dose for IV UFH infusion should be calculated based on indication; heparin bolus/loading dose should be skipped.

Converting from SubQ dalteparin dosed twice daily:

• IV UFH infusion should be started 10 to 11 hours after the last dose of dalteparin.

Converting from SubQ dalteparin dosed once daily:

• IV UFH infusion should be started 22 to 23 hours after the last dose of dalteparin.

IV (off-label route):

• Give as a bolus IV injection or as a continuous infusion; recommended concentration for infusion is 20 units/mL (Fragmin Canadian product labeling).

Mechanism of action of Dalteparin (Fragmin):

• It is an analog to Low molecular heparin, which has a molecular mass of 4,000 to 6,096 daltons.
• The commercial product contains 3% to 15% of heparin with molecular masses ranging from 3% to 15 percent to 78% to 65% with a molecular weigh of 3,000 to 8,000 daltons to 14% to 26% with molecular loads >8,000 daltons.
• While dalteparin inhibits both factor Xa (thrombin), its anti-factor IIa to Xa activity (ratio = Xa to IIa is higher (ratio =4)

The onset of action:

• Anti-Xa activity begins within 1 to 2 hours

Duration of action:

• more than 12 hours

Distribution:

• V : 40 to 60 mL/kg

Protein binding:

• Low affinity for plasma proteins

Bioavailability:

• Subcutaneous: 87% ± 6%

Half-life elimination (route dependent):

• IV: Mean terminal half-life: 2.1 ± 0.3 hours (40 unit/kg/dose) to 2.3 ± 0.4 hours (60 unit/kg/dose); mean terminal half-life (anti-Xa activity): 5.7 ± 2.0 hours (5,000 unit dose in ckd requiring hemodialysis)
• Subcutaneous: Mean terminal half-life: 3 to 5 hours

Time to peak serum concentration:

• Subcutaneous: Anti-Xa activity: Nearly 4 hours

Excretion:

• Primarily by kidneys

International Brand Names of Dalteparin:

• Fragmin
• Conpac
• Eurodal
• Fragmin P Forte
• Fragmine
• Ligofragmin

Dalteparin Brand Names in Pakistan: