enoxaparin

Contraindicated in:

Hypersensitivity to enoxaparin, unfractionated heparin, or pork products;
Hypersensitivity to benzyl alcohol (multidose vial);
History of immune-mediated heparin-induced thrombocytopenia (HIT) within the past 100 days or in the presence of circulating antibodies;
Active, major bleeding.

Use Cautiously in:

Severe renal impairment (adjust dose);
Severe hepatic impairment;
Retinopathy (hypertensive or diabetic);
Uncontrolled hypertension;
Recent history of ulcer disease;
History of congenital or acquired bleeding disorder;
Women <45 kg and men <57 kg (↑ exposure to enoxaparin with ↑ risk of bleeding; weight-adjusted dosing recommended);
Malignancy;
History of HIT >100 days ago and no circulating antibodies present;
OB: Safety not established in pregnancy; should not be used in pregnant patients with prosthetic heart valves or inherited/acquired thrombophilias without careful monitoring; if used during pregnancy, use preservative-free formulation;
Lactation: Use while breastfeeding only if potential maternal benefit outweighs potential risk to infant;
Pedi: Safety and effectiveness not established in children; multidose vial contains benzyl alcohol, which can cause potentially fatal “gasping syndrome” in neonates;
Geri: Older adults may have ↑ risk of bleeding due to age-related ↓ in renal function.

Exercise Extreme Caution in:

Severe uncontrolled hypertension;
Bacterial endocarditis;
Bleeding disorders;
GI bleeding/ulceration/pathology;
Hemorrhagic stroke;
Recent CNS or ophthalmologic surgery;
History of thrombocytopenia related to heparin;
Spinal/epidural anesthesia or spinal puncture (↑ risk of spinal/epidural hematoma that may lead to long-term or permanent paralysis).

Adv. Reactions/Side Effects ⬆ ⬇

CV: edema

Derm: alopecia, ecchymoses, pruritus, rash, urticaria

F and E: hyperkalemia

GI: constipation, ↑liver enzymes, nausea, vomiting

GU: urinary retention

Hemat: anemia, BLEEDING, eosinophilia, thrombocytopenia

Local: erythema at injection site, hematoma, irritation, pain

MS: osteoporosis

Neuro: dizziness, headache, insomnia

Misc: fever

Interactions ⬆ ⬇

Drug-drug:

Risk of bleeding may be ↑ by concurrent use of warfarin, aspirin, thrombolytic agents, NSAIDs,dipyridamole, some penicillins, clopidogrel, eptifibatide, tirofiban, and dextran.

Route/Dosage ⬆ ⬇

Venous Thromboembolism Prophylaxis

SC (Adults ): Knee replacement surgery: 30 mg every 12 hr starting 12–24 hr after surgery for 7–10 days; Hip replacement: 30 mg every 12 hr starting 12–24 hr after surgery or 40 mg once daily starting 12 hr before surgery (either dose may be continued for 7–14 days; continued prophylaxis with 40 mg once daily may be continued for up to 3 wk); Abdominal surgery: 40 mg once daily starting 2 hr before surgery and then continued for 7–12 days or until ambulatory (up to 14 days); Medical patients with acute illness: 40 mg once daily for 6–14 days.
SC (Infants and Children ≥2 mo —18 yr): 0.5 mg/kg every 12 hr.
SC (Infants 1–2 mo): 0.75 mg/kg every 12 hr.

Renal Impairment

SC (Adults ): CCr <30 mL/min: 30 mg once daily.

Treatment of Deep Vein Thrombosis/Pulmonary Embolism

SC (Adults ): Outpatient: 1 mg/kg every 12 hr. Warfarin should be started within 72 hr; enoxaparin may be continued for a minimum of 5 days and until therapeutic anticoagulation with warfarin is achieved (INR >2 for 2 consecutive days); Inpatient: 1 mg/kg every 12 hr or 1.5 mg/kg every 24 hr. Warfarin should be started within 72 hr; enoxaparin may be continued for a minimum of 5 days or until therapeutic anticoagulation with warfarin is achieved (INR >2 for two consecutive days).
SC (Infants and Children ≥2 mo —18 yr): 1 mg/kg every 12 hr.
SC (Infants 1–2 mo): 1.5 mg/kg every 12 hr.

Renal Impairment

SC (Adults ): CCr <30 mL/min: 1 mg/kg once daily.

Unstable Angina/Non-ST-Segment-Elevation Myocardial Infarction

SC (Adults ): 1 mg/kg every 12 hr for 2–8 days (with aspirin).

Renal Impairment

SC (Adults ): CCr <30 mL/min: 1 mg/kg once daily.

ST-Segment-Elevation Myocardial Infarction

IV SC (Adults <75 yr): Administer single IV bolus of 30 mg plus 1 mg/kg SUBQ dose (maximum of 100 mg for first 2 doses only), followed by 1 mg/kg SUBQ every 12 hr. The usual duration of treatment is 2–8 days. In patients undergoing percutaneous coronary intervention, if last SUBQ dose was <8 hr before balloon inflation, no additional dosing needed; if last SUBQ dose was ≥8 hr before balloon inflation, administer single IV bolus of 0.3 mg/kg.
SC (Adults ≥75 yr): 0.75 mg/kg every 12 hr (no IV bolus needed) (maximum of 75 mg for first 2 doses only; no initial bolus). The usual duration of treatment is 2–8 days.

Renal Impairment

SC (Adults <75 yr): CCr <30 mL/min: Single IV bolus of 30 mg plus 1 mg/kg SUBQ dose, followed by 1 mg/kg SUBQ once daily.

Renal Impairment

SC (Adults ≥75 yr): CCr <30 mL/min: 1 mg/kg once daily (no initial bolus).

Availability ⬆ ⬇

(Generic available)

Solution for injection (prefilled syringes): 30 mg/0.3 mL; 40 mg/0.4 mL; 60 mg/0.6 mL; 80 mg/0.8 mL; 100 mg/mL; 120 mg/0.8 mL; 150 mg/mL
Solution for injection (vials): 300 mg/3 mL

Assessment ⬆ ⬇

Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry stools; hematuria; fall in hematocrit or BP; guaiac-positive stools); bleeding from surgical site. Notify health care professional if these occur.
- Assess patient for evidence of additional or increased thrombosis. Symptoms depend on area of involvement.
- Assess location, duration, intensity, and precipitating factors of anginal pain.
- Monitor patient for hypersensitivity reactions (chills, fever, urticaria). Report signs to health care professional.
- Monitor patients with epidural catheters frequently for signs and symptoms of neurologic impairment. Delay placement or removal of catheter for at least 12 hr after administration of lower doses (30 mg once or twice daily or 40 mg once daily) and at least 24 hr after administration of higher doses (0.75 mg/kg twice daily, 1 mg/kg twice daily, or 1.5 mg/kg once daily) of enoxaparin. Do not give 2nd enoxaparin dose in twice daily regimen to patients receiving 0.75 mg/kg twice daily dose or 1 mg/kg twice daily dose to allow a longer delay before catheter placement or removal, then delay next dose for at least 4 hr. For patients with CCr <30 mL/min, double timing of removal of catheter, at least 24 hr for lower dose (30 mg once daily) and at least 48 hr for higher dose (1 mg/kg/day). Monitor for signs and symptoms of neurological impairment (midline back pain, sensory and motor deficits [numbness or weakness in lower limbs], bowel and/or bladder dysfunction) frequently if epidural or spinal anesthesia or lumbar puncture is done during therapy.
SC: Observe injection sites for hematomas, ecchymosis, or inflammation.

Lab Test Considerations:

Monitor CBC, platelet count, and stools for occult blood periodically during therapy. If thrombocytopenia occurs, monitor closely. If hematocrit decreases unexpectedly, assess patient for potential bleeding sites.
- Special monitoring of clotting times (aPTT) is not necessary in most patients. Monitoring of the aPTT may be considered in certain patient populations (such as obese patients or patients with renal insufficiency).
- Monitoring of antifactor Xa levels may be necessary to titrate doses in pediatric patients Therapeutic range 0.5–1 unit/mL.
- May cause ↑ in AST and ALT levels.
- May cause hyperkalemia.

Toxicity and Overdose:

For overdose, protamine sulfate 1 mg for each mg of enoxaparin should be administered by slow IV injection.

Implementation ⬆ ⬇

Cannot be used interchangeably (unit for unit) with unfractionated heparin or other low-molecular-weight heparins.
SC: Administer deep into SUBQ tissue. To avoid loss of drug, do not expel air bubble from prefilled syringe before injection. Alternate injection sites daily between the left and right anterolateral and left and right posterolateral abdominal wall. Inject entire length of needle at a 45° or 90° angle into a skin fold held between thumb and forefinger; hold skin fold throughout injection. Do not aspirate or massage. Rotate sites frequently. Do not administer IM because of danger of hematoma formation. Solution is clear, colorless to pale yellow; do not inject solution containing particulate matter.
- If excessive bruising occurs, ice-cube massage of site before injection may lessen bruising.
- Use a tuberculin syringe when using multidose vials to ensure correct dose.
- To minimize risk of bleeding after vascular instrumentation for unstable angina, recommended intervals between doses should be followed closely. Leave vascular access sheath in place for 6–8 hr after enoxaparin dose. Give next enoxaparin dose ≥6–8 hr after sheath removal. Observe site for bleeding or hematoma formation.

IV Administration:

IV Push: (for treatment of STEMI only)Use multiple-dose vial. Inject via IV line. Flush with 0.9% NaCl or D5W prior to and following administration to avoid mixture with other drugs and clear the port of the drug. May be administered with 0.9% NaCl or D5W. When administered with a thrombolytic, administer enoxaparin between 15 min before and 30 min after start of fibrinolytic therapy.
Rate: Inject as a bolus.
Y-Site Incompatibility: Do not mix or coadminister with other medications.

Patient/Family Teaching ⬆ ⬇

Instruct patient in correct technique for self-injection, care, and disposal of equipment.
Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to health care professional immediately.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications.
Instruct patient not to take aspirin, naproxen, or ibuprofen without consulting health care professional while on enoxaparin therapy.
Instruct patient to notify health care professional of therapy before dental or medical treatment or surgery.
Rep: Advise patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Monitor for evidence of bleeding or excessive anticoagulation. Consider use of a shorter acting anticoagulant as delivery approaches. Women with mechanical prosthetic heart valves may be at higher risk for thromboembolism during pregnancy, and, when pregnant, have a higher rate of fetal loss from stillbirth, spontaneous abortion, and premature delivery. Frequently monitor peak and trough anti-factor Xa levels; adjustment of dose may be needed.

ROUTE	ONSET	PEAK	DURATION
SUBQ	unknown	3–5 hr	12 hr

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

Availability ⬆ ⬇

Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

Evaluation/Desired Outcomes ⬆ ⬇

US Brand Names ⬆ ⬇

Canadian Brand Names ⬆