Therapeutic Classification: anticoagulants
Pharmacologic Classification: antithrombotics, low molecular weight heparins
Absorption: ~100% absorbed after SUBQ administration.
Distribution: Unknown.
Metabolism/Excretion: Metabolized in the liver, primarily renally eliminated. Clearance ↓ by 30% in renal impairment (CCr <30 mL/min).
Half-Life: Single dose: 4.5 hr; Repeat dosing: 7 hr.
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).
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).
