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.

Duration of therapy: At least 5 days and until a therapeutic oral anticoagulant effect has been achieved (INR 2 to 3). Average duration is 7 days; up to 17 days has been well tolerated in controlled clinical trials.

Comments: In both outpatient and inpatient treatments, warfarin sodium therapy should be initiated when appropriate (usually within 72 hours of commencing enoxaparin).

Uses:

• Outpatient treatment of acute deep vein thrombosis (DVT) without pulmonary embolism (PE) when administered in conjunction with warfarin sodium.
• Inpatient treatment of acute DVT with or without PE when administered in conjunction with warfarin sodium.

Usual Adult Dose for Deep Vein Thrombosis - Prophylaxis

40 mg subcutaneously once a day

Duration of therapy: Usually 6 to 11 days; up to 14 days has been well tolerated in clinical trials.

Use: Prophylaxis of deep vein thrombosis (DVT) in medical patients at risk for thromboembolic complications due to severely restricted mobility during acute illness.

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 a day)

Duration of therapy: At least 2 days and until clinical stabilization. Usual duration is 2 to 8 days; up to 12.5 days has been well tolerated in clinical trials.

Use: Prophylaxis of ischemic complications of unstable angina and non Q wave myocardial infarction, when concurrently administered with aspirin.

Acute ST-Segment Elevation Myocardial Infarction (STEMI):
30 mg IV bolus once plus 1 mg/kg subcutaneously once 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)

Duration of therapy: Optimal duration is unknown, but it is likely to be longer than 8 days.

Comments:

• 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 a day unless contraindicated).
• For patients managed by percutaneous coronary intervention (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 IV bolus of 0.3 mg/kg should be given.

Use: Prophylaxis of recurrent myocardial infarction or death in patients with acute STEMI receiving thrombolysis and being managed medically or with PCI, when concurrently administered with aspirin.

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 a day)

Duration of therapy: At least 2 days and until clinical stabilization. Usual duration is 2 to 8 days; up to 12.5 days has been well tolerated in clinical trials.

Use: Prophylaxis of ischemic complications of unstable angina and non Q wave myocardial infarction, when concurrently administered with aspirin.

Acute ST-Segment Elevation Myocardial Infarction (STEMI):
30 mg IV bolus once plus 1 mg/kg subcutaneously once 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)

Duration of therapy: Optimal duration is unknown, but it is likely to be longer than 8 days.

Comments:

• 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 a day unless contraindicated).
• For patients managed by percutaneous coronary intervention (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 IV bolus of 0.3 mg/kg should be given.

Use: Prophylaxis of recurrent myocardial infarction or death in patients with acute STEMI receiving thrombolysis and being managed medically or with PCI, when concurrently administered with aspirin.

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 a day)

Duration of therapy: At least 2 days and until clinical stabilization. Usual duration is 2 to 8 days; up to 12.5 days has been well tolerated in clinical trials.

Use: Prophylaxis of ischemic complications of unstable angina and non Q wave myocardial infarction, when concurrently administered with aspirin.

Acute ST-Segment Elevation Myocardial Infarction (STEMI):
30 mg IV bolus once plus 1 mg/kg subcutaneously once 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)

Duration of therapy: Optimal duration is unknown, but it is likely to be longer than 8 days.

Comments:

• 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 a day unless contraindicated).
• For patients managed by percutaneous coronary intervention (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 IV bolus of 0.3 mg/kg should be given.

Use: Prophylaxis of recurrent myocardial infarction or death in patients with acute STEMI receiving thrombolysis and being managed medically or with PCI, when concurrently administered with aspirin.

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.

Duration of therapy: Usually 7 to 10 days; up to 14 days has been well tolerated in clinical trials.

Uses:

• Prophylaxis of deep vein thrombosis (DVT) in patients undergoing hip replacement surgery, during and following hospitalization.
• Prophylaxis of DVT in patients undergoing knee replacement surgery.

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.

Duration of therapy: Usually 7 to 10 days; up to 14 days has been well tolerated in clinical trials.

Uses:

• Prophylaxis of deep vein thrombosis (DVT) in patients undergoing hip replacement surgery, during and following hospitalization.
• Prophylaxis of DVT in patients undergoing knee replacement surgery.

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

Duration of therapy: Usually 7 to 10 days; up to 12 days has been well tolerated in clinical trials.

Use: Prophylaxis of deep vein thrombosis (DVT) in patients undergoing abdominal surgery who are at risk for thromboembolic complications.

Usual Geriatric Dose for Myocardial Infarction

75 Years or Older:
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).

Comments:

• Do not use an initial IV bolus.
• No dose adjustments are required for other indications unless kidney function is impaired.

Use: Treatment of acute ST-segment elevation myocardial infarction.

Usual Pediatric Dose for Deep Vein Thrombosis

American College of Chest Physicians (ACCP) recommends the following:
Less than 2 months: 1.5 mg/kg subcutaneously every 12 hours
2 months to 17 years: 1 mg/kg subcutaneously every 12 hours

Usual Pediatric Dose for Deep Vein Thrombosis - Prophylaxis

American College of Chest Physicians (ACCP) recommends the following:
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

Renal Dose Adjustments

Mild to moderate renal dysfunction (CrCl 30 to 80 mL/min): Use with caution
Severe renal dysfunction (CrCl less than 30 mL/min):

• Prophylaxis in abdominal surgery: 30 mg subcutaneously once a day
• Prophylaxis in hip or knee replacement surgery: 30 mg subcutaneously once a day
• Prophylaxis in medical patients during acute illness: 30 mg subcutaneously once a day
• Outpatient treatment of acute deep vein thrombosis (DVT) without pulmonary (PE) (in conjunction with warfarin therapy): 1 mg/kg subcutaneously once a day
• Inpatient treatment of acute DVT with or without PE (in conjunction with warfarin therapy): 1 mg/kg subcutaneously once a day
• Prophylaxis of ischemic complications of unstable angina and non Q wave myocardial infarction (administered with aspirin): 1 mg/kg subcutaneously once a day
• Treatment of acute ST-segment elevation myocardial infarction (STEMI) in patients less than 75 years old (administered with aspirin): 30 mg IV bolus once plus 1 mg/kg subcutaneously once followed by 1 mg/kg subcutaneously once a day
• Treatment of acute STEMI in patients 75 years or older (administered with aspirin): 1 mg/kg subcutaneously once a day (no initial bolus)

Liver Dose Adjustments

Use with caution

Precautions

US BOXED WARNING:

• SPINAL/EPIDURAL HEMATOMAS: Epidural or spinal hematomas may occur in patients who are anticoagulated with low molecular weight heparins (LMWH) or heparinoids and are receiving neuraxial anesthesia or undergoing spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients for spinal procedures. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include: use of indwelling epidural catheters; concomitant use of other drugs that affect hemostasis such as non-steroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants; history of traumatic or repeated epidural or spinal punctures; history of spinal deformity or spinal surgery; optimal timing between the administration of this drug and neuraxial procedures is not known. Monitor patients frequently for signs and symptoms of neurological impairment. If neurological compromise is noted, urgent treatment is necessary. Consider the benefits and risks before neuraxial intervention in patients anticoagulated or to be anticoagulated for thromboprophylaxis.

Safety and efficacy have not been established in patients younger than 18 years.

Consult WARNINGS section for additional precautions.

Dialysis

Data not available

Other Comments

Administration advice: The manufacturer product information should be consulted.

Storage requirements: Do not store multiple-use vials for more than 28 days after the first use.

Reconstitution/preparation techniques: The manufacturer product information should be consulted.

IV compatibility:

• For subcutaneous use, this drug should not be mixed with other injections or infusions.
• For IV use, this drug can be mixed with normal saline solution (0.9%) or 5% dextrose in water.

General: This drug is characterized by a higher ratio of antithrombotic (anti-Factor Xa) activity to anticoagulant (anti-Factor IIa) activity compared to heparin.

Monitoring:

• Hematologic: Coagulation tests and complete blood count (the manufacturer product information and institution-specific protocol should be consulted).

Patient advice:

• If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential harm to the fetus and the mother.
• Instruct patients to inform a healthcare professional immediately if they experience any signs or symptoms of neurological impairment, such as midline back pain, sensory and motor deficits (numbness or weakness in lower limbs), or bowel and/or bladder dysfunction.