Suggested max loading dose: 400 U and 900 U/h INF or 5000 U loading dose/1000 U/h if pt weight >100 kg Bleeding with ASA; bleeding risk with other AP, AT, and GP IIb/IIIa; vigilantly monitor aPTT LMWH Cleared renally; more predictable dose response than UFH; not dependent on plasma protein levels; levels with lean body mass; effect with age Bleeding risk with age and weight and renally dosed Enoxaparin: Weight-based 1 mg/kg SC q 12 h; CrCl* <30 mL/min avoid or 1 mg/kg SC q 24 h; CrCl Dalteparin: Use caution in older pts with low body weight or renal insufficiency Bleed with ASA Monitor anti-Xa; bleeding with GP IIb/IIIa with age Direct Thrombin Inhibitors Bivalirudin Cleared renally; more predictable dose response; not dependent on plasma protein levels Significantly less bleeding in older pts, even with renal dysfunction vs. UFH + GP IIb/IIIa with similar efficacy CrCl <30 mL/min: 1 mg/kg/h; CrCl: 30 to 60 mL/min less bleeding than UFH Less bleeding than GP IIb/IIIa inhibitor + heparin Fondaparinux Cleared renally Renal/weight adjust; less bleeding but similar efficacy vs. enoxaparin in older pts with NSTE-ACS, even with mild to moderate renal dysfunction Renal adjustment: CrCl over enoxaparin Bleeding vs. enoxaparin; good safety profile vs. UFH/LMWH Inhibitors Clopidogrel Lipophilic; HPR; metabolism; fat distribution; to steady state ( fat distribution/T ) Antiplatelet effect in some older pts Maintenance: 75 mg (no response to higher dose) Effect with proton pump inhibitors; if HPR may respond to prasugrel or ticagrelor Prasugrel l9% Active metabolite >75 y of age Bleeding risk Avoid in pts 75 y of age or if weight 60 kg; 10 mg in very high-risk pts N/A Ticagrelor None known N/A None Reversible GP IIb/IIIa Inhibitors Abciximab N/A Bleeding with age Not recommended N/A Bleeding risk without clinical benefit Table B. 