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enoxaparin
generic
Black Box Warnings .
Spinal/Epidural Hematomas
may occur in anticoagulated pts receiving neuraxial anesthesia or spinal puncture; hematoma may result in long-term or permanent paralysis; incr. hematoma risk if indwelling epidural catheter use, concomitant use of drugs affecting hemostasis incl. NSAIDs, platelet inhibitors or other anticoagulants, traumatic or repeated epidural/spinal puncture hx, spinal deformity, or spinal surgery hx; weigh risk/benefit before neuraxial intervention in anticoagulated pts or planned anticoagulation for thromboprophylaxis; while optimal timing to minimize risk is unknown, delay spinal catheter placement or removal >12h after prophylactic doses and >24h after tx doses; consider delaying post-procedural dose >4h after catheter removal; for pts w/ CrCl <30, consider delaying spinal catheter placement or removal >24h after prophylactic doses and >48h after tx doses; monitor s/sx neurologic impairment frequently, treat urgently if needed
Adult Dosing .
Dosage forms: INJ (pre-filled syringe): 30 mg per 0.3 mL, 40 mg per 0.4 mL, 60 mg per 0.6 mL, 80 mg per 0.8 mL, 100 mg per mL, 120 mg per 0.8 mL, 150 mg per mL; INJ (vial): 100 mg per mL
DVT prophylaxis, hip replacement
- [BMI <40 kg/m^2]
- Dose: 30 mg SC q12h x7-10 days; Start: 12-24h postop; Alt: 40 mg SC qd x7-10 days, start 12h preop; Info: may cont. 40 mg SC qd x3wk as extended prophylaxis; D/C if Plt <100,000
- [BMI >40 kg/m^2 (off-label)]
- Dose: 40 mg SC q12h; Start: 12-24h postop; Alt: 0.5 mg/kg/dose SC q12-24h, use ABW to calculate dose; Info: D/C if Plt <100,000; refer to ACCP guidelines
DVT prophylaxis, knee replacement
- [BMI <40 kg/m^2]
- Dose: 30 mg SC q12h x7-10 days; Start: 12-24h postop; Info: D/C if Plt <100,000
- [BMI >40 kg/m^2 (off-label)]
- Dose: 40 mg SC q12h; Start: 12-24h postop; Alt: 0.5 mg/kg/dose SC q12-24h, use ABW to calculate dose; Info: D/C if Plt <100,000; refer to ACCP guidelines
DVT prophylaxis, abdominal surgery
- [BMI <40 kg/m^2]
- Dose: 40 mg SC qd x7-10 days; Start: 2h preop; Info: D/C if Plt <100,000
- [BMI >40 kg/m^2 (off-label)]
- Dose: 40 mg SC q12h; Start: 2h preop; Alt: 0.5 mg/kg/dose SC q12-24h, use ABW to calculate dose; Info: D/C if Plt <100,000; refer to ACCP guidelines
DVT prophylaxis, restricted mobility
- [BMI <40 kg/m^2]
- Dose: 40 mg SC qd x6-11 days; Info: D/C if Plt <100,000
- [BMI >40 kg/m^2 (off-label)]
- Dose: 40 mg SC q12h; Alt: 0.5 mg/kg/dose SC q12-24h, use ABW to calculate dose; Info: D/C if Plt <100,000; refer to ACCP guidelines
DVT/PE tx, inpatient
- [1 mg/kg/dose SC q12h]
- Alt: 1.5 mg/kg/dose SC qd; Info: cont. for >5 days and overlap w/ warfarin until INR 2-3 x24h; D/C if Plt <100,000
DVT w/o PE tx, outpatient
- [1 mg/kg/dose SC q12h]
- Info: cont. for >5 days and overlap w/ warfarin until INR 2-3 x24h; D/C if Plt <100,000
angina, unstable
- [1 mg/kg/dose SC q12h]
- Info: for ischemic complications prophylaxis; give w/ aspirin; cont. for >2 days until pt stabilized; D/C if Plt <100,000
NQWMI
- [1 mg/kg/dose SC q12h]
- Info: for ischemic complications prophylaxis; give w/ aspirin; cont. for >2 days until pt stabilized; D/C if Plt <100,000
STEMI
- [thrombolytic adjunct, <75 yo]
- Dose: 1 mg/kg/dose SC q12h; Start: 30 mg IV plus 1 mg/kg/dose SC x1, between 15min before and 30min after starting thrombolytic tx; Max: 100 mg/dose for first 2 SC doses; Info: give w/ aspirin; cont. for 8 days or until hospital D/C; D/C if Plt <100,000
- [thrombolytic adjunct, 75 yo and older]
- Dose: 0.75 mg/kg/dose SC q12h; Start: between 15min before and 30min after starting thrombolytic tx; Max: 75 mg/dose for first 2 doses; Info: give w/ aspirin; cont. for 8 days or until hospital D/C; D/C if Plt <100,000
- [PCI adjunct, <75 yo]
- Dose: 1 mg/kg/dose SC q12h; Start: 30 mg IV plus 1 mg/kg/dose SC x1; Max: 100 mg/dose for first 2 SC doses; Info: give 0.3 mg/kg/dose IV x1 if last dose >8h before PCI; D/C if Plt <100,000
- [PCI adjunct, 75 yo and older]
- Dose: 0.75 mg/kg/dose SC q12h; Max: 75 mg/dose for first 2 doses; Info: give 0.3 mg/kg/dose IV x1 if last dose >8h before PCI; D/C if Plt <100,000
VTE prophylaxis, cardioversion (off-label)
- [afib/flutter duration <48h]
- Dose: 1 mg/kg/dose SC q12h; Start: ASAP before or immediately after cardioversion; Info: for pts w/ CHA2DS2-VASc score >2; continue tx w/ oral anticoagulant for at least 4wk after procedure; D/C if Plt <100,000; refer to ACC/AHA/HRS guidelines
- [afib/flutter duration >48h or unknown]
- Dose: 1 mg/kg/dose SC q12h; Start: at least 3wk before cardioversion; Info: start ASAP if immediate cardioversion needed for hemodynamic instability; continue tx w/ oral anticoagulant for at least 4wk after procedure; D/C if Plt <100,000; refer to ACC/AHA/HRS guidelines
DVT prophylaxis, bariatric surgery (off-label)
- [BMI 40-50 kg/m^2]
- Dose: 40 mg SC q12h; Start: 30min-2h preop; Info: D/C if Plt <100,000; refer to American Society of Metabolic and Bariatric Surgery Clinical guidelines
- [BMI >50 kg/m^2]
- Dose: 60 mg SC q12h; Start: 30min-2h preop; Info: D/C if Plt <100,000; refer to American Society of Metabolic and Bariatric Surgery Clinical guidelines
perioperative anticoagulation bridging (off-label)
- [1 mg/kg/dose SC q12h]
- Start: 3 days preop; Alt: 1.5 mg/kg/dose SC qd; Info: for pts w/ high VTE risk who require VKA interruption; D/C 24h before surgery or invasive procedure; resume tx >24h postop and overlap w/ warfarin until therapeutic INR; D/C if Plt <100,000; refer to ACCP guidelines
renal dosing
- [DVT prophylaxis]
- CrCl <30: 30 mg qd
- HD/PD: not defined
- [DVT/PE tx, unstable angina, NQWMI]
- CrCl <30: 1 mg/kg/dose qd
- HD/PD: not defined
- [STEMI, <75 yo]
- CrCl <30: 30 mg IV plus 1 mg/kg/dose SC x1, then 1 mg/kg/dose SC qd
- HD/PD: not defined
- [STEMI, 75 yo and older]
- CrCl <30: 1 mg/kg/dose qd
- HD/PD: not defined
- [off-label uses]
- renal impairment: not defined
- HD/PD: not defined
hepatic dosing
- [see below]
- hepatic impairment: not defined, caution advised
Peds Dosing .
- Dosage forms: INJ (pre-filled syringe): 30 mg per 0.3 mL, 40 mg per 0.4 mL, 60 mg per 0.6 mL, 80 mg per 0.8 mL, 100 mg per mL, 120 mg per 0.8 mL, 150 mg per mL; INJ (vial): 100 mg per mL
thromboembolism prophylaxis (off-label)
- [<2 mo]
- Dose: 0.75 mg/kg/dose SC q12h; Info: adjust dose to anti-Xa levels 0.1-0.3 units/mL; D/C if Plt <100,000
- [2 mo and older]
- Dose: 0.5 mg/kg/dose SC q12h; Info: adjust dose to anti-Xa levels 0.1-0.3 units/mL; D/C if Plt <100,000
thromboembolism tx (off-label)
- [<2 mo]
- Dose: 1.5 mg/kg/dose SC q12h; Info: adjust dose to anti-Xa levels 0.5-1 units/mL; D/C if Plt <100,000
- [2 mo and older]
- Dose: 1 mg/kg/dose SC q12h; Info: adjust dose to anti-Xa levels 0.5-1 units/mL; D/C if Plt <100,000
renal dosing
- [adjust dose amount, frequency]
- CrCl 10-29: decr. usual dose by 30% or give usual dose q24h; CrCl <10: give 50% usual dose q24h
- HD/PD: not defined
hepatic dosing
- [see below]
- hepatic impairment: not defined, caution advised