Enoxaparin Dosage

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Usual Adult Dose for Deep Vein Thrombosis - Prophylaxis

40 mg subcutaneously once a day. The usual duration of administration is 6 to 11 days; up to 14 days administration has been well tolerated in clinical trials.

In morbidly obese patients (BMI of 40 kg/m2 or greater), increasing the prophylactic dose by 30% may be appropriate.

Usual Adult Dose for Deep Vein Thrombosis

Outpatient: 1 mg/kg subcutaneously every 12 hours
Inpatient: 1 mg/kg subcutaneously every 12 hours or 1.5 mg/kg subcutaneously once a day at the same time every day. In both outpatient and inpatient treatments, warfarin sodium therapy should be initiated on the same day of starting enoxaparin. Enoxaparin should be continued for a minimum of 5 days and until a therapeutic oral anticoagulant effect has been achieved (INR 2.0 to 3.0). The average duration of administration is 7 days; up to 17 days of has been well tolerated in controlled clinical trials.

Obesity: Use actual body weight to calculate dose; dose capping not recommended; use of twice daily dosing preferred.

Usual Adult Dose for Myocardial Infarction

Unstable angina and non Q wave myocardial infarction:
1 mg/kg subcutaneously every 12 hours in conjunction with oral aspirin therapy (100 to 325 mg once daily).
Obesity: Use actual body weight to calculate dose; dose capping not recommended.
Treatment should be given for a minimum of 2 days and continued until clinical stabilization. The vascular access sheath for instrumentation should remain in place for 6 to 8 hours following a dose of enoxaparin. The next scheduled dose should be given no sooner than 6 to 8 hours after sheath removal. The usual duration of treatment is 2 to 8 days; up to 12.5 days has been well tolerated in clinical trials.

Acute ST segment elevation myocardial infarction:
A single 30 mg intravenous bolus plus a 1 mg/kg subcutaneous dose followed by 1 mg/kg subcutaneously every 12 hours (maximum 100 mg for the first two doses only, followed by 1 mg/kg for the remaining doses).
Obesity: Use weight based dosing; a maximum dose of 100 mg is recommended for the first 2 doses.

When given in conjunction with a thrombolytic, enoxaparin should be given between 15 minutes prior and 30 minutes after the start of fibrinolytic treatment. All patients should be given oral aspirin therapy (75 to 325 mg once daily unless contraindicated). An optimal duration of treatment is unknown, but it is likely to be longer than 8 days. In patients receiving thrombolytics, initiate enoxaparin dosing between 15 minutes before and 30 minutes after fibrinolytic therapy. For patients managed by PCI, if the last subcutaneous dose of enoxaparin was less than 8 hours before balloon inflation, no additional dosing is required. If the last subcutaneous dose was given more than 8 hours before balloon inflation, an intravenous bolus of 0.3 mg/kg should be given.

Usual Adult Dose for Angina Pectoris

Unstable angina and non Q wave myocardial infarction:
1 mg/kg subcutaneously every 12 hours in conjunction with oral aspirin therapy (100 to 325 mg once daily).
Obesity: Use actual body weight to calculate dose; dose capping not recommended.
Treatment should be given for a minimum of 2 days and continued until clinical stabilization. The vascular access sheath for instrumentation should remain in place for 6 to 8 hours following a dose of enoxaparin. The next scheduled dose should be given no sooner than 6 to 8 hours after sheath removal. The usual duration of treatment is 2 to 8 days; up to 12.5 days has been well tolerated in clinical trials.

Acute ST segment elevation myocardial infarction:
A single 30 mg intravenous bolus plus a 1 mg/kg subcutaneous dose followed by 1 mg/kg subcutaneously every 12 hours (maximum 100 mg for the first two doses only, followed by 1 mg/kg for the remaining doses).
Obesity: Use weight based dosing; a maximum dose of 100 mg is recommended for the first 2 doses.

When given in conjunction with a thrombolytic, enoxaparin should be given between 15 minutes prior and 30 minutes after the start of fibrinolytic treatment. All patients should be given oral aspirin therapy (75 to 325 mg once daily unless contraindicated). An optimal duration of treatment is unknown, but it is likely to be longer than 8 days. In patients receiving thrombolytics, initiate enoxaparin dosing between 15 minutes before and 30 minutes after fibrinolytic therapy. For patients managed by PCI, if the last subcutaneous dose of enoxaparin was less than 8 hours before balloon inflation, no additional dosing is required. If the last subcutaneous dose was given more than 8 hours before balloon inflation, an intravenous bolus of 0.3 mg/kg should be given.

Usual Adult Dose for Acute Coronary Syndrome

Unstable angina and non Q wave myocardial infarction:
1 mg/kg subcutaneously every 12 hours in conjunction with oral aspirin therapy (100 to 325 mg once daily).
Obesity: Use actual body weight to calculate dose; dose capping not recommended.
Treatment should be given for a minimum of 2 days and continued until clinical stabilization. The vascular access sheath for instrumentation should remain in place for 6 to 8 hours following a dose of enoxaparin. The next scheduled dose should be given no sooner than 6 to 8 hours after sheath removal. The usual duration of treatment is 2 to 8 days; up to 12.5 days has been well tolerated in clinical trials.

Acute ST segment elevation myocardial infarction:
A single 30 mg intravenous bolus plus a 1 mg/kg subcutaneous dose followed by 1 mg/kg subcutaneously every 12 hours (maximum 100 mg for the first two doses only, followed by 1 mg/kg for the remaining doses).
Obesity: Use weight based dosing; a maximum dose of 100 mg is recommended for the first 2 doses.

When given in conjunction with a thrombolytic, enoxaparin should be given between 15 minutes prior and 30 minutes after the start of fibrinolytic treatment. All patients should be given oral aspirin therapy (75 to 325 mg once daily unless contraindicated). An optimal duration of treatment is unknown, but it is likely to be longer than 8 days. In patients receiving thrombolytics, initiate enoxaparin dosing between 15 minutes before and 30 minutes after fibrinolytic therapy. For patients managed by PCI, if the last subcutaneous dose of enoxaparin was less than 8 hours before balloon inflation, no additional dosing is required. If the last subcutaneous dose was given more than 8 hours before balloon inflation, an intravenous bolus of 0.3 mg/kg should be given.

Usual Adult Dose for Deep Vein Thrombosis Prophylaxis after Hip Replacement Surgery

30 mg subcutaneously every 12 hours. Provided that hemostasis has been established, the initial dose should be given 12 to 24 hours after surgery. For hip replacement surgery, a dose of 40 mg subcutaneously once a day given initially 12 hours prior to surgery may be considered. Following the initial phase of thromboprophylaxis in hip replacement surgery patients, continued prophylaxis with 40 mg subcutaneously once a day for 3 weeks is recommended. The usual duration of administration is 7 to 10 days; up to 14 days administration has been well tolerated in clinical trials.

In morbidly obese patients (BMI of 40 kg/m2 or greater), increasing the prophylactic dose by 30% may be appropriate.

Usual Adult Dose for Deep Vein Thrombosis Prophylaxis after Knee Replacement Surgery

30 mg subcutaneously every 12 hours. Provided that hemostasis has been established, the initial dose should be given 12 to 24 hours after surgery. For hip replacement surgery, a dose of 40 mg subcutaneously once a day given initially 12 hours prior to surgery may be considered. Following the initial phase of thromboprophylaxis in hip replacement surgery patients, continued prophylaxis with 40 mg subcutaneously once a day for 3 weeks is recommended. The usual duration of administration is 7 to 10 days; up to 14 days administration has been well tolerated in clinical trials.

In morbidly obese patients (BMI of 40 kg/m2 or greater), increasing the prophylactic dose by 30% may be appropriate.

Usual Adult Dose for Deep Vein Thrombosis Prophylaxis after Abdominal Surgery

40 mg subcutaneously once a day with the initial dose given 2 hours prior to surgery. The usual duration of administration is 7 to 10 days; up to 12 days administration has been well tolerated in clinical trials.

Bariatric surgery:Roux en Y gastric bypass: Appropriate dosing strategies have not been clearly defined.
BMI less than or equal to 50 kg/m2: 40 mg subcutaneously every 12 hours
BMI greater than 50 kg/m2: 60 mg subcutaneously every 12 hours

Note: Bariatric surgery guidelines suggest initiation 30 to 120 minutes before surgery and postoperatively until patient is fully mobile. Alternatively, limiting administration to the postoperative period may reduce perioperative bleeding.

Usual Geriatric Dose for Myocardial Infarction

Acute ST segment elevation myocardial infarction:
Patients greater than or equal to 75 years of age: No initial IV bolus.
Initial dose: 0.75 mg/kg subcutaneously every 12 hours (maximum 75 mg for first two doses only, followed by 0.75 mg/kg for the remaining doses).
No dose adjustments are required for other indications unless kidney function is impaired.

Usual Pediatric Dose for Deep Vein Thrombosis - Prophylaxis

less than 2 months: 0.75 mg/kg subcutaneously every 12 hours.

2 months to 17 years: 0.5 mg/kg subcutaneously every 12 hours.

Usual Pediatric Dose for Deep Vein Thrombosis

less than 2 months: 1.5 mg/kg subcutaneously every 12 hours.
2 months to 17 years: 1 mg/kg subcutaneously every 12 hours.

Alternate dosing:
Note: Several recent studies suggest that higher doses (especially in preterm neonates, neonates, and young infants) than those recommended. Some centers are using the following; however, further studies are needed to validate these proposed higher initial doses.
Premature neonates: 2 mg/kg/dose every 12 hours
Full term neonates: 1.7 mg/kg/dose every 12 hours
Infants less than 3 months: 1.8 mg/kg/dose every 12 hours
3 to 12 months: 1.5 mg/kg/dose every 12 hours
1 to 5 years: 1.2 mg/kg/dose every 12 hours
6 to 18 years: 1.1 mg/kg/dose every 12 hours

Renal Dose Adjustments

The following dosage regimens are recommended by the manufacturer in patients with a creatinine clearance less than 30 mL/min:

Prophylaxis in abdominal surgery: 30 mg subcutaneously once daily

Prophylaxis in hip or knee replacement surgery: 30 mg subcutaneously once daily

Prophylaxis in medical patients during acute illness: 30 mg subcutaneously once daily

Prophylaxis of ischemic complications of unstable angina and non Q wave MI (administered with aspirin): 1 mg/kg subcutaneously once daily

Treatment of acute DVT with or without PE (in conjunction with warfarin therapy): 1 mg/kg subcutaneously once daily

Outpatient treatment of acute DVT without PE (in conjunction with warfarin therapy): 1 mg/kg subcutaneously once daily

Treatment of acute ST segment elevation MI in patients less than 75 years old: single 30 mg intravenous bolus plus a 1 mg/kg subcutaneous dose followed by 1 mg/kg subcutaneously once daily.

Liver Dose Adjustments

According to the manufacturer, enoxaparin should be used with caution in patients with hepatic dysfunction.

Dose Adjustments

Enoxaparin Dosage Titration for Neonates, Infants, and Children:

Antifactor Xa less than 0.35 units/mL: Increase dose by 25%; repeat antifactor Xa level 4 hours after next dose
Antifactor Xa 0.35 to 0.49 units/mL: Increase dose by 10%; repeat antifactor Xa level 4 hours after next dose
Antifactor Xa 0.5 to 1 unit/mL: Keep same dosage; repeat antifactor Xa level next day, then 1 week later, then monthly (4 hours after dose)
Antifactor Xa 1.1 to 1.5 units/mL: Decrease dose by 20%; repeat antifactor Xa level before next dose
Antifactor Xa 1.6 to 2 units/mL: Hold dose for 3 hours and decrease dose by 30%; repeat antifactor Xa level before next dose, then 4 hours after next dose
Antifactor Xa greater than 2 units/mL: Hold all doses until antifactor Xa is 0.5 units/mL, then decrease dose by 40%; repeat antifactor Xa level before next dose and every 12 hours until antifactor Xa less than 0.5 units/mL

Precautions

All patients should be screened prior to prophylactic administration of enoxaparin to rule out a bleeding disorder. Elderly patients and patients with renal insufficiency may show delayed elimination of enoxaparin. Enoxaparin should be used with care in these patients.

For percutaneous coronary revascularization procedures, to minimize the risk of bleeding following vascular instrumentation during the treatment of unstable angina, non Q wave myocardial infarction (MI) and acute ST segment elevation MI, it is recommended that intervals between enoxaparin doses be adhered to precisely. Following PCI, hemostasis should be achieved at the puncture site prior to sheath removal. The sheath can be removed immediately if a closure device is used. The sheath can be removed 6 hours after the last enoxaparin dose, if a manual compression method is used. In the event that enoxaparin is to be continued, the next dose should be given no sooner than 6 to 8 hours after sheath removal. It is also recommended that the procedure site be observed for bleeding or hematoma formation.

Enoxaparin is contraindicated in patients with active major bleeding, thrombocytopenia, and patients with hypersensitivity to benzyl alcohol and/or pork products.

Use with caution in patients with a history of heparin-induced thrombocytopenia and those at an increased risk of bleeding. Therapy should be discontinued in the event of severe hemorrhage.

Thrombocytopenia has occurred during therapy with enoxaparin and discontinuation of therapy is recommended if the platelet count falls below 100,000/mm3.

Enoxaparin is intended for subcutaneous and intravenous administration. It should not be administered by intramuscular injection.

Safety and effectiveness have not been established in pediatric patients (less than 18 years of age).

Dialysis

Data not available

Other Comments

Periodic complete blood counts, including platelets, and stool occult blood tests have been recommended.

Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are unsuitable for monitoring enoxaparin anticoagulant activity.

Anti factor Xa may be used to monitor enoxaparin anticoagulant activity, particularly in patients with significant renal dysfunction.

Enoxaparin is administered by deep subcutaneous injection while the patient is lying down. The injection site should be varied daily between the left and right anterolateral and left and right posterolateral abdominal wall. In order to minimize bruising the injection site should not be rubbed following completion of the injection.

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