AHEAD TO THE FUTURE - BEMIMED · AHEAD TO THE FUTURE. HIBOR Features LMWH investigated, ... CLEXAN...

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HIBOR HIBOR ® ® PROPHYLAXIS PROPHYLAXIS (2.500 (2.500 and and 3.500 UI) 3.500 UI) TREATMENT TREATMENT (5.000, 7.500 (5.000, 7.500 and and 10.000 IU) 10.000 IU) AHEAD TO THE FUTURE

Transcript of AHEAD TO THE FUTURE - BEMIMED · AHEAD TO THE FUTURE. HIBOR Features LMWH investigated, ... CLEXAN...

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HIBORHIBOR®®

PROPHYLAXISPROPHYLAXIS(2.500 (2.500 andand 3.500 UI)3.500 UI)

TREATMENTTREATMENT(5.000, 7.500 (5.000, 7.500 andand 10.000 IU)10.000 IU)

AHEAD TO THE FUTURE

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HIBOR HIBOR FeaturesFeatures

LMWH investigated, developed and marketed by LMWH investigated, developed and marketed by ROVI in ROVI in 19981998

ROVI ROVI is the Spanish leader in the development of heparins.is the Spanish leader in the development of heparins.

ROVI ROVI manufactures many of the LMWH in the market.manufactures many of the LMWH in the market.

BEMIPARINBEMIPARIN

CLEXANE, INNOHEP, BOXOL CLEXANE, INNOHEP, BOXOL andand DECIPARDECIPAR

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HIBOR HIBOR BenefitBenefit

Spanish current productSpanish current product

PRIDE AND PREJUDICEPRIDE AND PREJUDICEPRIDE AND PREJUDICE

Investigating and reference laboratory for the rest of Investigating and reference laboratory for the rest of heparinsheparins

QUALITYQUALITYQUALITY

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HIBOR HIBOR Action mechanismAction mechanism

Potency of antiPotency of anti--FXaFXa activity and minimally activity and minimally antianti--FIIaFIIa activity. activity.

Potency of ATPotency of AT-- III action, III action, Physiological inhibitor of coagulationPhysiological inhibitor of coagulation

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Plasmatic coagulation systemPlasmatic coagulation system

INTRINSIC ROUTEINTRINSIC ROUTE EXTRINSIC ROUTEEXTRINSIC ROUTE

FT (FIII), FT (FIII), (FVII) a ((FVII) a (FVIIaFVIIa))

FXII, FXI, FIX, FVIIIFXII, FXI, FIX, FVIII

FXIIaFXIIa, , FXIaFXIa, , FIXaFIXa, , FVIIIaFVIIIa

FXaFXaFXFX

PROTHROMBIN (FII)PROTHROMBIN (FII) to to THROMBIN (THROMBIN (FIIaFIIa))

FIBRINOGEN (FI)FIBRINOGEN (FI) to to FIBRIN (FIBRIN (FIaFIa))(FXIII) a ((FXIII) a (FXIIIaFXIIIa))INSOLUBLEINSOLUBLE

FIBRINFIBRIN

CaCa++++

ATAT--IIIIIIATAT-- IIIIII

HIBORHIBOR

CaCa++++

TFPITFPITFPITFPI

HIBORHIBOR

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HIBOR HIBOR FeaturesFeatures

Fractionating method of UFH Fractionating method of UFH ((ββ--eliminactioneliminaction in nonin non--aqueous medium)aqueous medium)

Exclusive and innovating method patented by Exclusive and innovating method patented by ROVIROVI, which allows , which allows an optimum and balanced distribution of the fragmentsan optimum and balanced distribution of the fragments

ROVI ROVI has the only heparin fractionating plant existing in Spainhas the only heparin fractionating plant existing in Spain

LMWH of second generationLMWH of second generation

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LMWHLMWHDistribution of molecular weight Distribution of molecular weight BemiparinBemiparin

FragmentsFragments< 2000< 2000

FragmentsFragments20002000--60006000

FragmentsFragments> 6000> 6000

FragmentsFragments> 8000> 8000

EnoxaparinEnoxaparin DalteparinDalteparin NadroparinNadroparin

1111’’7%7%

7474’’6%6%

1313’’3%3%

44’’9%9%

Mean MWMean MW(D)(D) 36003600

1717’’7%7%

5959’’2%2%

2323’’9%9%

1111’’4%4%

44’’2%2%

5151’’9%9%

4949’’3%3%

2828’’6%6%

66’’2%2%

6464’’0%0%

2929’’4%4%

1515’’8%8%

45004500 60006000 45004500

UFHUFH

1500015000

ARIXTRAARIXTRA

17281728

SECOND SECOND GENERATIONGENERATION FIRST GENERATIONFIRST GENERATION

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LMWHLMWHantianti--FXa/antiFXa/anti--FIIaFIIa activityactivity

TinzaparinTinzaparin 2/12/1

NadroparinNadroparin 33’’2/12/1

DalteparinDalteparin 22’’5/15/1

EnoxaparinEnoxaparin 22’’7/17/1

BemiparinBemiparin 8/18/1

UFHUFH 1/11/1

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HIBOR HIBOR antianti--FXa/antiFXa/anti--FIIaFIIa::

8/18/1Mean molecular weight:Mean molecular weight:

3600 3600 daltonsdaltons

Best BENEFIT/RISK ratioBest BENEFIT/RISK ratio

It prevents the VTE due to its high It prevents the VTE due to its high antithromboticantithrombotic effect.effect.No bleeding risk, due to its minimum haemorrhagic effect. No bleeding risk, due to its minimum haemorrhagic effect.

EFFICACY AND SAFETYEFFICACY AND SAFETYEFFICACY AND SAFETY

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HIBOR HIBOR FeaturesFeatures

HIBORHIBOR 55’’3 h3 hCLEXANCLEXAN 22’’55--44’’5 h5 h

FRAGMINFRAGMIN 22’’2 h2 h

FRAXIPARINFRAXIPARIN 22’’4 h4 h

INNOHEPINNOHEP 11’’5 h5 h

UFHUFH 1 h1 h

LMWHLMWH HalfHalf--lifelife Bioavailability (sc)Bioavailability (sc)

96%96%96%96%

96%96%

96%96%

96%96%

1010--30%30%

ARIXTRAARIXTRA 1717--21 h21 h 100%100%

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HIBORHIBORIndicationsIndications

HIBOR PROPHYLAXISHIBOR PROPHYLAXIS (2.500 and 3.500 UI)(2.500 and 3.500 UI)

Prevention of VTE in patients subject to generalPrevention of VTE in patients subject to generalor orthopaedic surgeryor orthopaedic surgery

Prevention of VTE in nonPrevention of VTE in non--surgical patientssurgical patientsunder high or mild riskunder high or mild risk

Prevention of coagulation in the extracorporeal Prevention of coagulation in the extracorporeal circuit during circuit during haemodyalisishaemodyalisis

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BEMIPARIN vs UFH IN THE PREVENTION OFETEV IN HIP ARTHOPLASTIA

DESIGN•Multicentre, prospective, comparative, randomised, double blind in 298 patients subject to hip arthroplasty.

•Bemiparin 3,500 UI/day, sc, or UFH/12 h, 2h before surgery, x 12±4days.

•Efficacy parameters:

- Incidence of DVT and PE

•Safety parameters:

• Major/minor haemorrhages

• Intraoperational blood losses

• Transfussions required

• Post operation bleeding (haematoma in the injury, reintervention, etc)

• Follow up: 4 weeks after discharge from hospital

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EFFICACY OF BEMIPARIN IN THE PREVENTION OF ETEV IN HIP ARTHOPLASTIA

Parameters

PE

DVT

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SHORT TERM TREATMENTSHORT TERM TREATMENT

Treatment of established DVT,Treatment of established DVT,with or without pulmonary embolismwith or without pulmonary embolism

LONG TERM TREATMENTLONG TERM TREATMENT

PrevenciPrevencióónn secundariasecundaria de la de la recurrenciarecurrenciade de tromboembolismotromboembolismo venosovenoso en en pacientespacientescon TVP y con TVP y factoresfactores de de riesgoriesgo transitoriostransitorios

Secondary prevention of venous Secondary prevention of venous thromboembolismthromboembolismrecurrence in patientsrecurrence in patients

with DVT & transient risk factorswith DVT & transient risk factors

BEMIPARINBEMIPARINIndicationsIndications

(3.500 IU)(3.500 IU)

(5.000, 7.500 & 10.000 IU)(5.000, 7.500 & 10.000 IU)

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BEMIPARIN IN THE INITIAL AND LONG-TERM TREATMENT OF ETEV

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EFFICACY OF BEMIPARIN vs UFH IN THE INITIAL TREAMENT OF ETEV

PATIENTS SHOWING IMPROVEMENT IN THE MARDER SCORE(DAY 1 TO 14)

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BEMIPARIN IN THE LONG-TERM TREATMENT OF ETEV (I)

PATIENTS WITH RECHANNELING OF THE THROMBUS(DAY 1 TO 84)

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LMWHLMWH (First generation)(First generation) /ARIXTRA/ARIXTRAIndicationsIndications

No indication of recurrenceNo indication of recurrenceThe findings of the different clinical trials are only valid The findings of the different clinical trials are only valid

for each particular type of LMWH used in the trialfor each particular type of LMWH used in the trialand and cannot be transferred to the restcannot be transferred to the rest

ARIXTRA has only approvedARIXTRA has only approved““Prevention of VTE in patients subject to major orthopaedic surgePrevention of VTE in patients subject to major orthopaedic surgeryry

in lower limbs, such as hip fracture, in lower limbs, such as hip fracture, major knee surgery or hip prosthesismajor knee surgery or hip prosthesis””

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FondaparinuxFondaparinuxWarnings and precautions for useWarnings and precautions for use

Care must be taken in the elderly, sinceCare must be taken in the elderly, sinceThe risk of major bleeding increases with ageThe risk of major bleeding increases with age

In patients In patients >> 75 years and/or with body weight < 50 75 years and/or with body weight < 50 kg and/or mild renal impairment,kg and/or mild renal impairment,

The first administration must not be given before The first administration must not be given before 6h have elapsed from the end of surgery.6h have elapsed from the end of surgery.

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The elimination of The elimination of FondaparinuxFondaparinux diminishes with weight, diminishes with weight, so care must be taken when used in patients weighing so care must be taken when used in patients weighing

< 50 kg< 50 kg

FondaparinuxFondaparinuxWarnings and precautions for useWarnings and precautions for use

In any case, its use is related to the increase of the risk In any case, its use is related to the increase of the risk of major bleeding episodesof major bleeding episodes

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HIBOR HIBOR BenefitBenefit

In the SPC of In the SPC of HIBORHIBOR these these warnings are not includedwarnings are not included

SAFETYSAFETYSAFETY

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HIBORHIBORDose: ProphylaxisDose: Prophylaxis

Prevention of VTE in patientsPrevention of VTE in patientsSubject to general or orthopaedic surgery.Subject to general or orthopaedic surgery.

HIBOR 2,500 IU/dHIBOR 2,500 IU/d(low/mild risk)(low/mild risk)

HIBOR 3,500 IU/dHIBOR 3,500 IU/d(high risk)(high risk)

2 hours before or 6 hours after 2 hours before or 6 hours after the interventionthe intervention

It is considered necessary to keep the prophylactic treatment atIt is considered necessary to keep the prophylactic treatment atleast for least for 7 to 10 days7 to 10 days after the intervention.after the intervention.

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DAILY DOSES OF THE DIFFERENT LMWH IN RELATION TO THE RISK GROUP

Low risk High risk

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Classic: 7-10 days or active deambulation

LENGTH OF THROMBOPROPHYLAXIS:BENEFITS OF PROLONGATION

DVT recurrence is maximum during the 1st month 1, 2

Demonstrated in oncologic surgery: enlargement of prophylaxis 28-35 days3

Lower number or recurrences1,2 and economic benefits3

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LENGTH OF ETEV PROPHYLAXIS

The optimum length of the prophylaxis is difficult to establish

Some studies have demonstrated that the risk of fatal PE remains in hip fractures up to 30 days after the originalaccident.

In hip arthoplastia, there is scientific evidence of level A to recommend the maintenance of the prophylaxis with LMWH between 29-35 days after surgery.

Many other studies recommend similar regimes for knee arthroplasty and other interventions of major Orthopaedic Surgery.

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HIBOR HIBOR Prevention of VTE in highPrevention of VTE in high--risk surgeryrisk surgery

HIBORHIBOR is the onlyis the only LMWH showing LMWH showing antithromboticantithromboticefficacy administered efficacy administered 6 hours after the 6 hours after the

beginning of the interventionbeginning of the intervention

HIBORHIBOR is the onlyis the only LMWH that can be LMWH that can be administered administered

2 hours before surgery2 hours before surgery(Patients receiving general anaesthetics)(Patients receiving general anaesthetics)

(Patients receiving spinal anaesthetics)(Patients receiving spinal anaesthetics)

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1st generation 1st generation LMWHLMWH(High risk)(High risk)

EnoxaparinEnoxaparin40 mg (4000 IU), sc 12 h before surgery40 mg (4000 IU), sc 12 h before surgery

40 mg/24 h, sc (740 mg/24 h, sc (7--10 d)10 d)

DalteparinDalteparin2500 IU, sc 22500 IU, sc 2--4 h before surgery and 2500 IU 12 h after4 h before surgery and 2500 IU 12 h after

5000 IU/24 h, sc (75000 IU/24 h, sc (7--10 d)10 d)

NadroparinNadroparin12 h before and 12 h after the intervention12 h before and 12 h after the intervention

Weight < 70 Kg: days 1a 3, 0Weight < 70 Kg: days 1a 3, 0’’3 ml and the rest 03 ml and the rest 0’’4 ml4 mlWeight > 70 Kg: days 1a 3, 0Weight > 70 Kg: days 1a 3, 0’’4 ml and the rest 04 ml and the rest 0’’6 ml6 ml

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EPIDURAL HAEMATOMA IN ETEV PROPHYLAXIS WITH NEUROAXIAL ANAESTHETICS

Unfrequent complication: 0.7/100.000

FDA 1997

•43 cases of spinal haematomas in patients treated with Enoxaparin and subject to raquideal anaesthetics

•75% were old age women subject to orthopaedic interventions

•Restrictive recommendations on the use of these techniques in patients treated with anticoagulants as prophylaxis.

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FACTORS THAT MAY INCREASE THE RISK OF SPINAL HAEMORRHAGE IN NEUROAXIAL

ANAESTHETICS

Anatomic alterations (canal stenosis)

Difficulties to perform the technique

Techniques with catheter colocation

Alterations of previous coagulations

Elderly patients

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PROPHYLAXIS WITH LMWH AND LOCOREGIONAL ANAESTHESIA

CIRCULAR LETTER 10/2001 OF AEM

In patients receiving heparin with therapeutic

and not prophylactic ones, regional anaesthetics

is indicated in scheculed surgery.The insertion or withdrawal or an epidural or spinal catheter must be done after at least 12 hours after the last prophylactic dose of LMWH.Once the catheter has been inserted or withdrawn, at least 4 hours until the new administration of the dose must elapse.

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DESIGN OF THE STUDY WITH BEMIPARIN IN THE ANTITHROMBOTIC PROPHYLAXIS FOR KNEE

SURGERY

•Patients subject to knee arthroplasty

•General anaesthetics

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EFFICACY OF BEMIPARIN IN THE ANTITHROMBOTIC PROPHYLAXIS FOR TOTAL

KNEE ARTHROPLASTY

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PRACTICAL CONSEQUENCES OF POSTOPERATORY PROPHYLAXIS

The postoperatory prophylaxis regime of ETEV facilitates the performance of spinal/epidural anaesthetic techniques minimising the risk of spinal haemorrhagic complications.

The patient does not need to be hospitalised the day before surgery for heparinisation:

- Health costs could be reduced.- It facilitates major surgery procedures.

The possible influence of preoperative administration of heparins on the increase of intraoperative bleeding is avoided.

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LEGAL ASPECTS RELATED TO THE USE OF LMWH IN ETEV PROPHYLAXIS

LEGAL OPINION“(…) the safest way of eluding responsibility for the administration of LMWH is to follow the indications stated in the summary of product characteristics, since not always does the specialist know the effects of the product with absolute certainty, as he is not responsible for the origin or supervision of the drug and, therefore, the only guarantee of its activity lays on such observance of the indications.

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FondaparinuxFondaparinuxDoseDose

2.5 mg/24 hours, subcutaneous injection2.5 mg/24 hours, subcutaneous injectionStarting 6 hours after the end of surgery,Starting 6 hours after the end of surgery,

Provided that Provided that hemostasishemostasis has been has been restablishedrestablished

The efficacy and safety of the treatment with The efficacy and safety of the treatment with ArixtraArixtra has not been established has not been established for more than 9 days.for more than 9 days.

““Should it be necessary to consider a prolongedShould it be necessary to consider a prolongedanticoagulant treatment, the patient should be administered anticoagulant treatment, the patient should be administered

a treatment with proved experience in longa treatment with proved experience in long--term useterm use””

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HIBOR HIBOR Prophylaxis: DoseProphylaxis: Dose

Prevention of VTE in nonPrevention of VTE in non--surgical patientssurgical patientswith high or mild riskwith high or mild risk

HIBOR 2,500 IU/dHIBOR 2,500 IU/d HIBOR 3,500 IU/dHIBOR 3,500 IU/d

Depending on the set of risk factors that the patient presents dDepending on the set of risk factors that the patient presents defining him efining him as mild or high as mild or high tromboembolictromboembolic patient.patient.

The prophylactic treatment must continue, according to the doctoThe prophylactic treatment must continue, according to the doctorr’’s s criterion, throughout the risk period or until the complete mobicriterion, throughout the risk period or until the complete mobilization of lization of

the patient. the patient.

oror

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HIBOR HIBOR Prophylaxis: DoseProphylaxis: Dose

Prevention of coagulation in the extracorporeal Prevention of coagulation in the extracorporeal circuit during haemodialysiscircuit during haemodialysis

1 SINGLE DOSE 1 SINGLE DOSE in bolus into the arterial linein bolus into the arterial lineof the dialysis circuit of the dialysis circuit at the beginning at the beginning of the process. of the process.

2,500 IU anti 2,500 IU anti FXaFXaPatients weighing less than 60 kgPatients weighing less than 60 kg

3,500 IU anti 3,500 IU anti FXaFXaPatients weighing more than 60 kgPatients weighing more than 60 kg

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SHORTSHORT--TERM TERM TREATMENTTREATMENT

Treatment of deep vein thrombosisTreatment of deep vein thrombosis

115 IU/kg/115 IU/kg/ddííaaby sc route, for 7 by sc route, for 7 ++ 2 days2 days

This regime depends on body weight:This regime depends on body weight:

< 50 kg, < 50 kg, 0.2 ml0.2 ml (5,000 IU)(5,000 IU)5050--70 kg, 70 kg, 0.3 ml0.3 ml (7,500 IU)(7,500 IU)>70 kg, >70 kg, 0.4 ml0.4 ml (10,000 IU)(10,000 IU)

HIBORHIBORTreatment: DoseTreatment: Dose

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HIBORHIBORTreatementTreatement: Dose: Dose

LONG TERM LONG TERM TREATMENTTREATMENT

Treatment of deep vein thrombosisTreatment of deep vein thrombosis

3,500 IU/day3,500 IU/dayby sc route, for 3 monthsby sc route, for 3 months

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BEMIPARINBEMIPARINGuidelines for good administrationGuidelines for good administration

Withdraw the protecting shield by turning slowlyWithdraw the protecting shield by turning slowlyand pulling upwards trying not to bend the needle.and pulling upwards trying not to bend the needle.

Do not try to put the shield back in place, as the Do not try to put the shield back in place, as the needle could be damaged.needle could be damaged.

BEMIPARINBEMIPARIN prefilledprefilled syringes are ready for use, syringes are ready for use, so it is not recommended to purge the fluid inside theso it is not recommended to purge the fluid inside thesyringe. syringe.

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BEMIPARINBEMIPARINGuidelines for good administration Guidelines for good administration

The injection site is the subcutaneous cellular tissue The injection site is the subcutaneous cellular tissue in the in the anterolateralanterolateral or or postlateralpostlateral abdominal waist.abdominal waist.Administer the injection in the opposite side Administer the injection in the opposite side of the waist in alternative days.of the waist in alternative days.

Choose the area where you will administer the injectionChoose the area where you will administer the injectionAnd disinfect it with a small piece of cotton wool And disinfect it with a small piece of cotton wool impregnated in alcohol or any other disinfectant. impregnated in alcohol or any other disinfectant.

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BEMIPARINABEMIPARINAGuidelines for good administrationGuidelines for good administration

Form a fold in the skin where the administration will Form a fold in the skin where the administration will take place (abdominal waist, one side of the belly)take place (abdominal waist, one side of the belly)

Without loosening the skin fold, place the syringe Without loosening the skin fold, place the syringe Perpendicularly to it and introduce the needle Perpendicularly to it and introduce the needle Completely.Completely.

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BEMIPARINBEMIPARINGuidelines for good administrationGuidelines for good administration

Slowly inject the content of the syringe by softly Slowly inject the content of the syringe by softly pressing the plunger rod to facilitate the pressing the plunger rod to facilitate the absorption of the drug. absorption of the drug. Keep the skin fold until the injection has finished Keep the skin fold until the injection has finished and the syringe has been withdrawn. and the syringe has been withdrawn.

Do not rub the area after the injection.Do not rub the area after the injection.Discard the syringe inside a rigid container,Discard the syringe inside a rigid container,to avoid accidental pricking. to avoid accidental pricking.

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HIBOR HIBOR PresentationsPresentations

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HIBOR 3500 IU HIBOR 3500 IU is theis the only LMWHonly LMWHthat has the approval for the presentation ofthat has the approval for the presentation of

3030 prefilledprefilled syringessyringes

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HIBOR 3,500 x 30 HIBOR 3,500 x 30 BenefitsBenefits

It prevents the patient from having to renew the It prevents the patient from having to renew the treatment continuously.treatment continuously.

The patient does not need to go back to the doctorThe patient does not need to go back to the doctor’’s s surgery, as surgery, as A ONEA ONE--OFF VISITOFF VISIT to the to the doctordoctor’’s will be enough. s will be enough.

EASE OF USEEASE OF USEEASE OF USE

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This presentation suits the recent recommendations of This presentation suits the recent recommendations of prolonging the prophylaxis of prolonging the prophylaxis of thromboembolicthromboembolic disease disease after high risk surgery for 25 or 30 days.after high risk surgery for 25 or 30 days.

Complete Complete thromboembolicthromboembolic prophylaxis in a single prophylaxis in a single container. container.

It facilitates patienceIt facilitates patience’’s compliance with the treatment. s compliance with the treatment.

SAFETYSAFETYSAFETY

HIBOR 3,500 x 30 HIBOR 3,500 x 30 BenefitsBenefits

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Lower costLower costComplete Complete thromboembolicthromboembolic prophylaxis in a single prophylaxis in a single prescriptionprescriptionThe number of prescriptions diminishes (savings in The number of prescriptions diminishes (savings in prescriptions), which contributes to the social health prescriptions), which contributes to the social health savings.savings.

ECONOMYECONOMYECONOMY

HIBOR 3,500 x 30 HIBOR 3,500 x 30 BenefitsBenefits

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HIBOR PROPHYLAXISHIBOR PROPHYLAXIS2500 & 3500 IU2500 & 3500 IU

Minimum quantity of solvent (Minimum quantity of solvent (0.2 ml0.2 ml))The same in both presentations.The same in both presentations.

EnoxaparinEnoxaparin20 & 40 mg (0.2 & 0.4 ml)20 & 40 mg (0.2 & 0.4 ml)

DalteparinDalteparin2500 & 5000 (0.2 ml)2500 & 5000 (0.2 ml)

NadroparinNadroparin2850, 3800 & 5700 IU2850, 3800 & 5700 IU

(0.3, 0.4 & 0.6 ml)(0.3, 0.4 & 0.6 ml)

TinzaparinTinzaparin3500 & 4500 IU3500 & 4500 IU(0.35 & 0.45 ml)(0.35 & 0.45 ml)

FondaparinuxFondaparinux2.5 mg (0.5 ml)2.5 mg (0.5 ml)

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Minimum solvent quantityMinimum solvent quantity

((0.20.2, , 0.30.3 & & 0.4 ml0.4 ml))

HIBOR TREATMENT5000, 7500 & 10000 IU

HIBOR TREATMENTHIBOR TREATMENT5000, 7500 & 10000 IU5000, 7500 & 10000 IU

EnoxaparinEnoxaparin(0.6, 0.8 &1 ml)(0.6, 0.8 &1 ml)

DalteparinDalteparin(0.3, 0.4, 0.5, 0.6 & 0.72 ml)(0.3, 0.4, 0.5, 0.6 & 0.72 ml)

NadroparinNadroparin(0.6, 0.8 & 1 ml)(0.6, 0.8 & 1 ml)

TinzaparinTinzaparin(0.35, 0.45, 0.5, 0.7 & 0.9 ml)(0.35, 0.45, 0.5, 0.7 & 0.9 ml)

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By the patient:By the patient:Minimum pain and Minimum pain and ecchymosisecchymosis

ACCEPTATIONACCEPTATIONACCEPTATION

HIBOR HIBOR BenefitsBenefits

For the doctor:For the doctor:It minimizes the number of urgency callsIt minimizes the number of urgency calls

EASE OF USEEASE OF USEEASE OF USE