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Enoxaparin

Sodium

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Enoxaparin

Sodium

Class

Heparins

Low

molecular

weight

Heparins

LMWHs

CAS

Number

Medically

reviewed

on

Oct

Overview

Side

Effects

Dosage

Professional

Tips

Interactions

Warning

SpinalEpidural

Hematoma

Risk

Epidural

or

spinal

hematomas

and

neurologic

injury

including

longterm

or

permanent

paralysis

associated

with

concurrent

use

of

low

molecular

weight

heparins

LMWHs

or

heparinoids

and

neuraxial

spinalepidural

anesthesia

or

spinal

puncture

Risk

increased

by

use

of

indwelling

epidural

catheters

or

by

concomitant

use

of

drugs

affecting

hemostasis

eg

NSAIAs

plateletaggregation

inhibitors

other

anticoagulants

Risk

also

increased

by

history

of

traumatic

or

repeated

epidural

or

spinal

puncture

spinal

deformity

or

spinal

surgery

Optimal

timing

between

administration

of

enoxaparin

and

neuraxial

procedures

not

known

Monitor

frequently

for

signs

and

symptoms

of

neurologic

impairment

and

treat

urgently

if

neurologic

compromise

noted

Consider

potential

benefits

versus

risks

of

spinal

or

epidural

anesthesia

or

spinal

puncture

in

patients

receiving

or

being

considered

for

thromboprophylaxis

with

anticoagulants

See

SpinalEpidural

Hematomas

under

Cautions

Introduction

Anticoagulant

an

LMWH

Uses

for

Enoxaparin

Sodium

Thromboprophylaxis

in

GeneralAbdominal

Surgery

Prevention

of

postoperative

DVT

which

may

lead

to

PE

in

patients

undergoing

generalabdominal

surgery

who

are

at

risk

for

thromboembolic

complications

The

American

College

of

Chest

Physicians

ACCP

recommends

pharmacologic

eg

LMWH

andor

nonpharmacologicmechanical

eg

intermittent

pneumatic

compression

methods

of

thromboprophylaxis

in

patients

undergoing

general

surgery

including

abdominal

GI

gynecologic

and

urologic

surgery

according

to

the

patients

risk

of

thromboembolism

and

bleeding

In

general

pharmacologic

prophylaxis

is

recommended

in

patients

with

high

and

possibly

moderate

risk

of

venous

thromboembolism

who

do

not

have

a

high

risk

of

bleeding

while

mechanical

methods

are

suggested

in

patients

who

require

thromboprophylaxis

but

have

a

high

risk

of

bleeding

If

pharmacologic

prophylaxis

is

used

in

patients

undergoing

general

surgery

ACCP

states

that

an

LMWH

or

lowdose

heparin

heparin

referring

throughout

this

monograph

to

unfractionated

heparin

is

preferred

Because

risk

of

venous

thromboembolism

is

particularly

high

in

patients

undergoing

abdominal

or

pelvic

surgery

for

cancer

extended

weeks

prophylaxis

with

an

LMWH

is

recommended

in

such

patients

ACCP

states

that

the

recommendations

for

use

of

antithrombotic

agents

in

general

surgery

patients

can

be

applied

to

patients

undergoing

bariatric

vascular

and

plasticreconstructive

surgery

Thromboprophylaxis

in

HipReplacement

KneeReplacement

or

HipFracture

Surgery

Prevention

of

postoperative

DVT

which

may

lead

to

PE

in

patients

undergoing

hipreplacement

surgery

Prevention

of

DVT

andor

PE

in

patients

undergoing

kneereplacement

surgery

Also

has

been

used

for

thromboprophylaxis

in

patients

undergoing

hipfracture

surgery

ACCP

recommends

routine

thromboprophylaxis

with

a

pharmacologic

andor

mechanical

method

in

all

patients

undergoing

major

orthopedic

surgery

because

of

high

risk

of

postoperative

venous

thromboembolism

continue

thromboprophylaxis

for

at

least

days

and

possibly

for

up

to

days

after

surgery

Several

antithrombotic

agents

eg

LMWHs

fondaparinux

lowdose

heparin

warfarin

aspirin

recommended

by

ACCP

for

pharmacologic

prophylaxis

during

major

orthopedic

surgery

When

selecting

an

appropriate

thromboprophylaxis

regimen

consider

factors

such

as

efficacy

safety

logistics

and

compliance

Medical

Conditions

Predisposing

to

Thromboembolism

Prevention

of

DVT

which

may

lead

to

PE

in

patients

with

severely

restricted

mobility

during

acute

illness

In

general

pharmacologic

thromboprophylaxis

recommended

only

in

patients

considered

to

be

at

high

risk

of

venous

thromboembolism

ACCP

recommends

anticoagulant

prophylaxis

eg

LMWH

in

acutely

ill

hospitalized

medical

patients

at

increased

risk

of

thrombosis

who

are

not

actively

bleeding

and

do

not

have

an

increased

risk

of

bleeding

Continued

thromboprophylaxis

suggested

for

days

until

full

mobility

is

restored

or

hospital

discharge

whichever

comes

first

Use

of

LMWHs

also

suggested

by

ACCP

for

pharmacologic

thromboprophylaxis

in

critically

ill

patients

eg

those

in

an

intensive

care

unit

ICU

who

are

not

actively

bleeding

and

do

not

have

risk

factors

for

bleeding

Risk

of

venous

thromboembolism

is

particularly

high

in

patients

with

cancer

Use

of

LMWH

prophylaxis

suggested

by

ACCP

in

cancer

outpatients

with

solid

tumors

who

have

additional

risk

factors

for

thromboembolism

provided

risk

of

bleeding

is

low

Treatment

and

Secondary

Prevention

of

Acute

DVT

andor

PE

Inpatient

treatment

of

acute

DVT

with

or

without

PE

when

administered

in

conjunction

with

warfarin

Outpatient

treatment

of

acute

DVT

without

PE

when

administered

in

conjunction

with

warfarin

Recommended

by

ACCP

as

an

appropriate

choice

of

anticoagulant

for

initial

treatment

of

acute

proximal

DVT

andor

PE

LMWHs

or

fondaparinux

generally

preferred

over

heparin

for

initial

treatment

of

acute

venous

thromboembolism

however

heparin

may

be

preferred

in

patients

with

renal

impairment

IV

heparin

also

may

be

preferred

over

LMWH

in

patients

with

PE

in

whom

thrombolytic

therapy

is

being

considered

or

if

there

is

concern

about

adequate

subQ

absorption

For

longterm

anticoagulant

therapy

secondary

prevention

warfarin

generally

preferred

in

patients

without

cancer

however

in

patients

with

cancer

ACCP

suggests

use

of

an

LMWH

because

of

a

possible

reduced

response

to

warfarin

in

such

patients

Continue

anticoagulant

therapy

for

at

least

months

and

possibly

longer

depending

on

individual

clinical

situation

NonSTSegmentElevation

Acute

Coronary

Syndromes

NSTE

ACS

Reduction

in

the

risk

of

acute

cardiac

ischemic

events

death

MI

in

patients

with

NSTE

ACS

unstable

angina

or

nonSTsegmentelevation

MI

NSTEMI

when

administered

concurrently

with

aspirin

andor

other

standard

therapy

eg

nitrates

βadrenergic

blocking

agents

βblockers

clopidogrel

platelet

glycoprotein

GP

IIbIIIareceptor

inhibitors

Initial

parenteral

anticoagulants

with

established

efficacy

in

patients

with

NSTE

ACS

include

enoxaparin

heparin

bivalirudin

only

in

patients

managed

with

an

early

invasive

strategy

and

fondaparinux

Also

used

in

patients

with

NSTE

ACS

undergoing

PCI

to

prevent

thrombus

formation

during

the

procedure

STSegmentElevation

MI

STEMI

Used

as

adjunctive

therapy

for

the

management

of

acute

STEMI

in

patients

receiving

thrombolysis

and

being

managed

medically

or

with

PCI

ACCF

and

AHA

state

that

patients

with

STEMI

undergoing

thrombolytic

therapy

should

receive

an

anticoagulant

eg

heparin

enoxaparin

fondaparinux

for

hours

and

preferably

for

the

duration

of

the

index

hospitalization

up

to

days

or

until

revascularization

is

performed

Enoxaparin

is

preferred

over

heparin

if

extended

anticoagulation

hours

is

necessary

Adjunctive

use

of

an

LMWH

in

patients

with

acute

STEMI

associated

with

improvement

in

shortterm

clinical

outcomes

eg

death

reinfarction

recurrent

ischemia

with

generally

similar

rates

of

bleeding

complications

compared

with

adjunctive

heparin

or

placebo

Also

used

in

patients

with

STEMI

undergoing

PCI

to

prevent

thrombus

formation

during

the

procedure

There

is

less

experience

with

enoxaparin

in

the

setting

of

primary

PCI

Treatment

of

Superficial

Vein

Thrombosis

LMWHs

also

have

been

used

for

treatment

of

spontaneous

superficial

vein

thrombosis

superficial

thrombophlebitis

ACCP

suggests

use

of

prophylactic

dosages

for

days

in

patients

with

superficial

vein

thrombosis

of

cm

in

length

Thromboprophylaxis

in

Cardiac

Surgery

Mechanical

methods

of

prophylaxis

generally

recommended

in

patients

undergoing

cardiac

surgery

however

ACCP

states

that

an

LMWH

may

be

considered

for

thromboprophylaxis

in

cardiac

surgery

patients

with

a

complicated

postoperative

course

Thromboprophylaxis

in

Thoracic

Surgery

Pharmacologic

thromboprophylaxis

eg

LMWH

recommended

by

ACCP

in

patients

undergoing

thoracic

surgery

who

are

at

high

risk

of

venous

thromboembolism

provided

risk

of

bleeding

is

low

Thromboprophylaxis

in

Neurosurgery

LMWHs

have

been

used

for

prevention

of

venous

thromboembolism

in

patients

undergoing

craniotomy

however

benefits

of

such

prophylaxis

may

be

outweighed

by

possible

increased

risk

of

intracranial

hemorrhage

ACCP

states

that

LMWH

prophylaxis

may

be

considered

in

patients

at

very

high

risk

of

thromboembolism

eg

those

undergoing

craniotomy

for

malignant

disease

once

adequate

hemostasis

established

and

risk

of

bleeding

decreases

Thromboprophylaxis

with

LMWHs

also

may

be

considered

in

highrisk

patients

undergoing

spinal

surgery

eg

those

with

malignancy

or

those

undergoing

surgery

with

a

combined

anteriorposterior

approach

once

adequate

hemostasis

established

and

risk

of

bleeding

decreases

Thromboprophylaxis

in

Trauma

May

be

used

for

thromboprophylaxis

in

patients

with

major

trauma

For

major

trauma

patients

at

high

risk

of

venous

thromboembolism

including

those

with

acute

spinal

cord

injury

traumatic

brain

injury

or

spinal

surgery

for

trauma

ACCP

suggests

use

of

both

a

pharmacologic

and

mechanical

method

of

prophylaxis

unless

contraindications

exist

Treatment

of

Renal

Vein

Thrombosis

Although

use

of

anticoagulant

therapy

for

renal

vein

thrombosis

most

common

cause

of

spontaneous

venous

thromboembolism

in

neonates

is

controversial

LMWHs

are

suggested

by

ACCP

as

a

possible

treatment

option

in

selected

neonates

Thromboprophylaxis

in

Acute

Ischemic

Stroke

Heparin

anticoagulants

ie

LMWH

or

heparin

have

been

used

for

thromboprophylaxis

in

selected

patients

with

acute

ischemic

stroke

those

with

additional

risk

factors

for

venous

thromboembolism

are

more

likely

to

benefit

from

such

prophylaxis

ACCP

suggests

thromboprophylaxis

with

an

LMWH

subQ

heparin

or

intermittent

pneumatic

compression

in

patients

with

acute

ischemic

stroke

and

restricted

mobility

LMWH

is

preferred

over

heparin

Prophylacticdose

heparin

heparin

or

an

LMWH

usually

initiated

within

hours

of

onset

of

stroke

and

continued

throughout

hospital

stay

until

patient

regains

mobility

do

not

administer

within

the

first

hours

after

thrombolytic

therapy

LMWHs

also

recommended

by

ACCP

as

an

option

for

initial

management

of

acute

arterial

ischemic

stroke

in

children

until

dissection

and

embolic

causes

have

been

excluded

If

arterial

ischemic

stroke

is

associated

with

dissection

or

a

cardioembolic

origin

continued

anticoagulant

therapy

suggested

In

children

with

acute

arterial

ischemic

stroke

secondary

to

nonMoyamoya

vasculopathy

ACCP

recommends

ongoing

antithrombotic

therapy

eg

with

an

LMWH

for

months

LMWHs

may

be

considered

in

neonates

with

a

first

episode

of

arterial

ischemic

stroke

associated

with

a

documented

cardioembolic

source

Thromboembolism

During

Pregnancy

Used

during

pregnancy

for

prevention

and

treatment

of

venous

thromboembolism

and

for

prevention

and

treatment

of

systemic

embolism

associated

with

mechanical

heart

valves

See

Treatment

and

Prevention

of

Thromboembolism

During

Pregnancy

under

Dosage

and

Administration

Also

has

been

used

in

combination

with

lowdose

aspirin

for

prevention

of

recurrent

pregnancy

loss

in

women

with

antiphospholipid

antibody

APLA

syndrome

LMWHs

rather

than

heparin

or

warfarin

are

recommended

by

ACCP

for

prevention

and

treatment

of

thromboembolism

during

pregnancy

In

pregnant

women

with

an

acute

venous

thromboembolic

event

ACCP

recommends

an

LMWH

for

initial

treatment

and

secondary

prevention

throughout

the

remainder

of

the

pregnancy

To

prevent

recurrence

of

postpartum

anticoagulation

for

weeks

and

for

a

total

duration

of

months

is

suggested

In

general

thromboprophylaxis

eg

with

an

LMWH

is

suggested

during

the

antepartum

period

only

in

pregnant

women

who

have

a

history

of

thromboembolism

and

are

considered

to

be

at

moderate

to

high

risk

of

recurrent

events

eg

those

with

a

single

episode

of

unprovoked

venous

thromboembolism

pregnancy

or

estrogenrelated

venous

thromboembolism

history

of

multiple

unprovoked

events

Postpartum

thromboprophylaxis

for

weeks

is

suggested

in

all

pregnant

women

with

a

prior

venous

thromboembolic

event

an

LMWH

in

prophylactic

or

intermediate

dosages

or

warfarin

INR

may

be

used

for

such

prophylaxis

Hereditary

thrombophilias

substantially

increase

risk

of

pregnancyrelated

venous

thromboembolism

a

family

history

of

venous

thromboembolism

further

increases

risk

ACCP

suggests

antepartum

and

postpartum

prophylaxis

with

an

LMWH

in

some

pregnant

women

with

highrisk

hereditary

thrombophilias

eg

homozygous

genetic

mutations

for

factor

V

Leiden

or

prothrombin

who

have

not

experienced

a

prior

venous

thromboembolic

event

but

have

a

family

history

of

thromboembolism

An

LMWH

has

been

used

in

combination

with

lowdose

aspirin

for

prevention

of

pregnancy

loss

in

women

with

antiphospholipid

antibodies

APLA

syndrome

and

recurrent

or

more

pregnancy

loss

Discontinue

LMWH

therapy

hours

prior

to

induction

of

labor

or

cesarean

section

or

expected

time

of

neuraxial

anesthesia

to

avoid

an

unwanted

anticoagulant

effect

on

fetus

Cardioversion

of

Atrial

FibrillationFlutter

LMWHs

have

been

used

for

prevention

of

stroke

and

systemic

embolism

in

patients

with

atrial

fibrillation

or

atrial

flutter

undergoing

electrical

or

pharmacologic

cardioversion

As

an

alternative

to

prolonged

anticoagulation

eg

usually

with

warfarin

prior

to

cardioversion

in

patients

with

atrial

fibrillation

lasting

hours

or

of

unknown

duration

LMWHs

in

therapeutic

dosages

may

be

used

at

the

time

of

transesophageal

echocardiography

TEE

followed

by

cardioversion

within

hours

if

no

thrombus

is

detected

In

patients

with

atrial

fibrillation

of

short

duration

eg

hours

LMWHs

in

therapeutic

dosages

may

be

used

at

presentation

followed

by

immediate

cardioversion

In

patients

with

hemodynamic

instability

who

require

urgent

cardioversion

ACCP

suggests

administration

of

a

parenteral

anticoagulant

in

therapeutic

dosages

prior

to

cardioversion

if

possible

however

such

anticoagulant

therapy

must

not

delay

any

emergency

intervention

After

successful

cardioversion

to

sinus

rhythm

all

patients

should

receive

therapeutic

anticoagulation

for

weeks

Thromboprophylaxis

in

Patients

with

Prosthetic

Heart

Valves

Used

during

conversion

to

maintenance

therapy

with

warfarin

to

reduce

the

incidence

of

thromboembolism

in

patients

with

prosthetic

mechanical

heart

valves

ACCP

suggests

bridging

anticoagulation

an

LMWH

in

either

prophylactic

or

therapeutic

dosages

or

IV

heparin

in

prophylactic

dosages

during

the

early

postoperative

period

after

insertion

of

a

mechanical

heart

valve

in

patients

without

bleeding

risk

until

an

adequate

response

to

warfarin

is

obtained

Also

may

be

used

for

bridging

anticoagulation

in

patients

with

a

mechanical

heart

valve

in

whom

therapy

with

warfarin

must

be

temporarily

discontinued

eg

those

undergoing

major

surgery

Has

been

used

for

thromboprophylaxis

in

pregnant

women

with

prosthetic

mechanical

heart

valves

See

Thromboembolism

During

Pregnancy

under

Uses

Venous

Thromboembolism

in

Pediatric

Patients

An

LMWH

has

been

used

for

treatment

and

secondary

prevention

of

venous

thromboembolism

in

pediatric

patients

venous

thromboembolism

usually

occurs

secondary

to

an

identifiable

risk

factor

eg

presence

of

central

venous

access

device

in

such

patients

Recommendations

regarding

use

of

antithrombotic

therapy

in

children

generally

based

on

extrapolation

from

adult

guidelines

ACCP

recommends

an

LMWH

or

heparin

for

both

initial

and

ongoing

treatment

of

venous

thromboembolism

in

children

Potential

advantages

of

an

LMWH

over

heparin

include

reduced

need

for

monitoring

lack

of

drug

or

dietary

interactions

reduced

risk

of

heparininduced

thrombocytopenia

HIT

and

possible

reduced

risk

of

osteoporosis

In

children

with

central

venous

catheterrelated

thromboembolism

ACCP

recommends

removal

of

catheter

if

no

longer

functioning

or

required

at

least

days

of

therapeutic

anticoagulation

is

suggested

prior

to

removal

If

such

catheters

must

remain

in

place

ACCP

suggests

anticoagulant

therapy

until

catheter

is

removed

Treatment

of

Cerebral

Venous

Sinus

Thrombosis

May

be

used

for

the

treatment

of

acute

cerebral

venous

sinus

sinovenous

thrombosis

in

adults

Once

patient

is

stable

may

convert

to

coumarin

anticoagulant

therapy

Reasonable

to

use

fulldose

LMWH

rather

than

heparin

for

treatment

of

acute

cerebral

venous

sinus

thrombosis

during

pregnancy

Prophylaxis

with

an

LMWH

during

pregnancy

and

the

postpartum

period

is

reasonable

in

women

with

history

of

cerebral

venous

sinus

thrombosis

Recommended

by

ACCP

as

an

option

for

initial

and

followup

anticoagulation

in

children

with

cerebral

venous

sinus

thrombosis

without

substantial

intracranial

hemorrhage

Also

has

been

suggested

for

use

in

children

with

substantial

hemorrhage

LMWHs

also

suggested

by

ACCP

as

a

treatment

option

for

neonates

with

cerebral

sinovenous

thrombosis

Perioperative

Antithrombotic

Prophylaxis

ACCP

suggests

use

of

an

LMWH

or

IV

heparin

during

temporary

interruption

of

warfarin

therapy

bridging

anticoagulation

in

selected

patients

with

venous

thromboembolism

atrial

fibrillation

or

mechanical

prosthetic

heart

valves

undergoing

surgery

or

other

invasive

procedures

use

and

type

of

bridging

anticoagulation

depend

on

patients

risk

of

developing

thromboembolism

without

warfarin

therapy

In

general

bridging

anticoagulation

is

suggested

in

such

patients

who

are

considered

to

be

at

particularly

high

risk

of

venous

thromboembolism

without

oral

anticoagulant

therapy

Enoxaparin

Sodium

Dosage

and

Administration

General

Since

routine

coagulation

parameters

such

as

PT

or

aPTT

are

insensitive

for

monitoring

enoxaparin

activity

routine

monitoring

of

coagulation

parameters

generally

not

required

Monitoring

of

antifactor

Xa

levels

may

be

helpful

in

highrisk

groups

such

as

pregnant

patients

patients

with

renal

impairment

patients

at

extremes

of

weight

or

if

abnormal

coagulation

parameters

or

bleeding

occurs

during

treatment

If

an

LMWH

is

used

for

anticoagulation

in

children

ACCP

suggests

that

dosage

be

adjusted

to

a

target

antifactor

Xa

level

of

unitsmL

based

on

a

sample

taken

hours

or

unitsmL

based

on

a

sample

taken

hours

following

subQ

administration

In

patients

with

unstable

angina

or

NSTEMI

adhere

precisely

to

intervals

recommended

between

doses

to

minimize

the

risk

of

bleeding

If

a

closure

device

is

used

may

remove

sheath

immediately

after

PCI

Otherwise

if

a

manual

compression

method

is

used

remove

vascular

access

sheath

hours

following

the

last

dose

of

enoxaparin

sodium

If

continuing

enoxaparin

sodium

therapy

administer

the

next

scheduled

dose

no

sooner

than

hours

after

sheath

removal

Observe

procedure

site

for

signs

of

bleeding

or

hematoma

formation

Administration

Administer

by

deep

subQ

injection

for

most

indications

do

not

give

IM

In

patients

with

acute

STEMI

administer

as

singledose

direct

IV

bolus

injection

followed

by

subQ

administration

Direct

IV

injection

also

used

in

selected

patients

with

unstable

angina

or

NSTEMI

undergoing

PCI

When

using

multipledose

vials

withdraw

the

dose

using

a

tuberculin

or

equivalent

syringe

Do

not

mix

enoxaparin

with

other

injections

or

infusions

IV

Administration

May

be

administered

by

direct

IV

injection

into

an

IV

line

Use

multipledose

vial

for

IV

administration

To

avoid

mixing

IV

enoxaparin

with

other

drugs

flush

IV

line

with

a

sufficient

amount

of

sodium

chloride

injection

or

dextrose

injection

prior

to

and

following

IV

administration

of

enoxaparin

SubQ

Administration

Patient

should

be

supine

during

administration

To

avoid

loss

of

drug

when

using

the

or

prefilled

syringes

do

not

expel

air

from

syringe

prior

to

injection

Inject

drug

subQ

into

the

left

and

right

anterolateral

and

left

and

right

posterolateral

abdominal

wall

Insert

the

entire

length

of

the

needle

into

a

skin

fold

created

by

the

thumb

and

forefinger

hold

the

skin

fold

until

the

needle

is

withdrawn

Alternate

injection

sites

frequently

To

minimize

bruising

do

not

massage

injection

sites

after

injection

Dosage

Available

as

enoxaparin

sodium

dosage

expressed

in

terms

of

the

salt

Dosages

for

enoxaparin

sodium

or

other

LMWHs

and

heparin

can

not

be

used

interchangeably

on

a

unitforunit

or

mgformg

basis

Available

as

enoxaparin

sodium

Enoxaparin

sodium

has

an

approximate

antifactor

Xa

activity

of

unitsmg

using

the

WHO

First

International

Low

Molecular

Weight

Heparin

Reference

Standard

Adults

Prevention

of

DVT

andor

PE

GeneralAbdominal

Surgery

SubQ

mg

once

daily

initiated

hours

prior

to

surgery

Usual

duration

of

therapy

is

days

although

up

to

days

of

treatment

has

been

well

tolerated

in

clinical

trials

Extended

prophylaxis

for

up

to

weeks

recommended

by

ACCP

in

patients

undergoing

abdominal

or

pelvic

surgery

for

cancer

HipReplacement

Surgery

SubQ

mg

every

hours

initiated

hours

after

surgery

provided

hemostasis

has

been

established

Alternatively

may

consider

dosage

of

mg

once

daily

initiated

approximately

hours

before

surgery

Because

of

risk

of

bleeding

ACCP

recommends

that

LMWHs

be

initiated

at

least

hours

preoperatively

or

at

least

hours

postoperatively

in

patients

undergoing

major

orthopedic

surgery

Continue

prophylaxis

throughout

the

postoperative

period

generally

for

days

until

risk

of

DVT

has

diminished

manufacturer

states

that

up

to

days

of

thromboprophylaxis

was

well

tolerated

in

clinical

trials

Following

the

initial

phase

of

thromboprophylaxis

during

the

acute

postoperative

period

manufacturer

recommends

continued

prophylaxis

with

mg

once

daily

for

weeks

ACCP

recommends

a

minimum

of

days

of

thromboprophylaxis

and

suggests

extending

prophylaxis

for

up

to

days

on

an

outpatient

basis

KneeReplacement

Surgery

SubQ

mg

every

hours

initiated

hours

after

surgery

provided

hemostasis

has

been

established

Because

of

risk

of

bleeding

ACCP

recommends

that

LMWHs

be

initiated

at

least

hours

preoperatively

or

hours

postoperatively

in

patients

undergoing

major

orthopedic

surgery

Continue

prophylaxis

throughout

the

postoperative

period

generally

for

days

until

risk

of

DVT

has

diminished

manufacturer

states

that

up

to

days

of

thromboprophylaxis

was

well

tolerated

in

clinical

trials

ACCP

recommends

a

minimum

of

days

of

thromboprophylaxis

and

suggests

extending

prophylaxis

for

up

to

days

on

an

outpatient

basis

Medical

Conditions

Predisposing

to

Thromboembolism

SubQ

Acute

illness

with

severely

restricted

mobility

eg

cancer

heart

failure

severe

lung

disease

patients

confined

to

bedrest

mg

once

daily

Usual

duration

of

therapy

is

days

well

tolerated

for

up

to

days

in

clinical

trials

ACCP

suggests

against

the

use

of

extended

thromboprophylaxis

beyond

the

period

of

patient

immobilization

or

acute

hospital

stay

in

acutely

ill

medical

patients

Treatment

of

DVT

with

or

without

PE

SubQ

Outpatient

treatment

at

home

in

patients

without

PE

mgkg

every

hours

Inpatient

hospital

treatment

in

patients

with

or

without

PE

who

are

not

candidates

for

outpatient

treatment

mgkg

every

hours

or

mgkg

once

daily

at

the

same

time

every

day

Average

duration

of

therapy

is

days

although

up

to

days

of

treatment

has

been

well

tolerated

in

clinical

trials

Initiate

concurrent

warfarin

therapy

when

appropriate

usually

within

hours

of

enoxaparin

injection

ACCP

recommends

initiating

warfarin

on

the

first

treatment

day

and

overlapping

therapy

with

warfarin

and

enoxaparin

for

days

and

until

the

INR

is

at

least

for

hours

NSTE

ACS

SubQ

mgkg

every

hours

in

conjunction

with

aspirin

therapy

mg

once

daily

Initiate

as

soon

as

possible

after

hospital

admission

Administer

for

a

minimum

of

days

and

continue

until

clinical

stabilization

Usual

duration

of

treatment

is

days

although

up

to

days

of

treatment

has

been

well

tolerated

in

clinical

trials

Patients

undergoing

PCI

who

have

not

received

prior

anticoagulant

therapy

ACCFAHASCAI

state

that

it

is

reasonable

to

administer

enoxaparin

sodium

eg

mgkg

by

direct

IV

injection

at

the

time

of

PCI

Patients

in

whom

subQ

enoxaparin

has

been

initiated

prior

to

PCI

upstream

ACCFAHASCAI

state

that

an

additional

dose

of

enoxaparin

sodium

should

be

given

by

direct

IV

injection

at

the

time

of

PCI

if

fewer

than

prior

therapeutic

eg

mgkg

subQ

doses

of

enoxaparin

sodium

have

been

given

or

if

the

last

subQ

dose

of

the

drug

was

administered

hours

before

PCI

To

minimize

the

possibility

of

bleeding

associated

with

vascular

eg

vascular

access

sheath

instrumentation

eg

PCI

adhere

strictly

to

dosage

intervals

and

observe

precautions

in

removing

vascular

access

sheath

Administer

next

dose

of

enoxaparin

sodium

no

sooner

than

hours

after

removal

of

vascular

access

sheath

ACCFAHASCAI

suggest

removal

of

femoral

sheath

when

ACT

falls

to

seconds

or

aPTT

falls

to

seconds

Monitor

vascular

access

sites

carefully

for

signs

of

bleeding

or

hematoma

formation

after

removal

of

vascular

sheath

and

during

enoxaparin

treatment

STEMI

IV

then

SubQ

Initial

dose

in

patients

years

of

age

mg

by

direct

IV

injection

Follow

with

mgkg

subQ

every

hours

maximum

mg

per

dose

for

each

of

the

first

subQ

doses

then

mgkg

per

dose

thereafter

give

first

subQ

dose

immediately

after

direct

IV

dose

See

Geriatric

Patients

under

Dosage

and

Administration

for

dosing

recommendations

in

patients

years

of

age

When

used

with

thrombolytic

therapy

initiate

enoxaparin

therapy

minutes

before

to

minutes

after

initiation

of

thrombolytic

therapy

Manufacturer

states

optimal

duration

not

known

but

likely

to

be

days

enoxaparin

therapy

was

continued

for

days

or

until

hospital

discharge

in

clinical

trials

Use

in

conjunction

with

aspirin

therapy

mg

once

daily

unless

contraindicated

Patients

undergoing

PCI

If

last

subQ

dose

of

enoxaparin

sodium

was

administered

hours

before

PCI

manufacturer

recommends

an

additional

dose

by

direct

IV

injection

during

PCI

To

minimize

the

possibility

of

bleeding

associated

with

vascular

eg

vascular

access

sheath

instrumentation

eg

PCI

adhere

strictly

to

dosage

intervals

and

observe

precautions

in

removing

vascular

access

sheath

Administer

next

dose

of

enoxaparin

sodium

no

sooner

than

hours

after

removal

of

vascular

access

sheath

ACCFAHASCAI

suggest

removal

of

femoral

sheath

after

PCI

when

ACT

falls

to

seconds

or

aPTT

falls

to

seconds

Monitor

vascular

access

sites

carefully

for

signs

of

bleeding

or

hematoma

formation

after

removal

of

vascular

sheath

and

during

enoxaparin

treatment

Treatment

and

Prevention

of

Thromboembolism

During

Pregnancy

SubQ

Treatment

of

acute

venous

thromboembolism

mgkg

every

hours

for

the

remainder

of

pregnancy

continue

anticoagulation

for

weeks

postpartum

minimum

total

duration

of

months

Postpartum

prophylaxis

in

pregnant

women

with

a

prior

venous

thromboembolic

event

Prophylactic

mg

once

daily

or

intermediate

mg

every

hours

dosage

suggested

Pregnant

women

receiving

longterm

coumarin

anticoagulation

eg

warfarin

An

LMWH

may

be

used

throughout

pregnancy

in

a

weightadjusted

dosage

eg

enoxaparin

sodium

mgkg

every

hours

or

of

a

weightadjusted

dosage

resume

longterm

anticoagulation

postpartum

Primary

prevention

of

venous

thromboembolism

in

pregnant

women

with

highrisk

thrombophilias

Prophylactic

mg

once

daily

or

intermediate

mg

every

hours

dosage

suggested

Pregnant

women

with

APLA

syndrome

Antepartum

administration

of

an

LMWH

in

prophylactic

dosages

recommended

by

ACCP

combine

with

lowdose

aspirin

mg

daily

Pregnant

women

with

mechanical

heart

valves

ACCP

recommends

an

LMWH

throughout

pregnancy

or

alternatively

an

LMWH

until

week

of

pregnancy

substituting

warfarin

until

close

to

delivery

then

resuming

LMWH

therapy

Twicedaily

administration

recommended

because

of

altered

pharmacokinetics

in

pregnant

women

with

adjustment

of

enoxaparin

sodium

dosage

to

maintain

antifactor

Xa

levels

of

unitsmL

hours

after

dosing

Resume

usual

longterm

anticoagulation

postpartum

See

Patients

with

Mechanical

Heart

Valves

under

Cautions

Consider

use

of

a

shorteracting

anticoagulant

as

delivery

approaches

To

avoid

an

unwanted

anticoagulant

effect

on

the

fetus

during

delivery

discontinue

LMWH

hours

prior

to

induction

of

labor

or

cesarean

section

Cardioversion

of

Atrial

FibrillationFlutter

SubQ

For

prevention

of

stroke

and

systemic

embolism

in

patients

undergoing

cardioversion

for

atrial

fibrillation

or

atrial

flutter

use

of

full

venous

thromboembolism

treatment

dosages

recommended

Perioperative

Antithrombotic

Prophylaxis

SubQ

For

bridging

anticoagulation

during

temporary

interruption

of

warfarin

therapy

in

patients

undergoing

surgery

or

other

invasive

procedures

ACCP

generally

recommends

therapeutic

dosages

of

a

LMWH

eg

enoxaparin

sodium

mgkg

twice

daily

or

mgkg

once

daily

Special

Populations

Hepatic

Impairment

No

special

population

dosage

recommendations

at

this

time

Renal

Impairment

Use

with

caution

in

renally

impaired

patients

No

dosage

adjustments

necessary

in

patients

with

mild

Cl

cr

mLminute

or

moderate

Cl

cr

mLminute

renal

impairment

Adjust

dosage

for

patients

with

severe

renal

impairment

Cl

cr

mLminute

DVT

andor

PE

Thromboprophylaxis

in

GeneralAbdominal

Surgery

SubQ

In

patients

with

severe

renal

impairment

Cl

cr

mLminute

mg

once

daily

Thromboprophylaxis

in

Hip

or

KneeReplacement

Surgery

SubQ

In

patients

with

severe

renal

impairment

Cl

cr

mLminute

mg

once

daily

Thromboprophylaxis

in

Medical

Conditions

Associated

with

Thromboembolism

SubQ

In

patients

with

severe

renal

impairment

Cl

cr

mLminute

mg

once

daily

Treatment

of

DVT

with

or

without

PE

SubQ

In

patients

with

severe

renal

impairment

Cl

cr

mLminute

mgkg

once

daily

in

conjunction

with

warfarin

therapy

NSTE

ACS

SubQ

In

patients

with

severe

renal

impairment

Cl

cr

mLminute

mgkg

once

daily

with

concurrent

aspirin

therapy

mg

once

daily

STEMI

IV

and

SubQ

In

patients

with

severe

renal

impairment

Cl

cr

mLminute

who

are

years

of

age

mg

as

a

single

direct

IV

dose

followed

by

mgkg

subQ

once

daily

not

to

exceed

mg

per

dose

for

the

first

subQ

doses

with

concurrent

aspirin

therapy

mg

daily

SubQ

In

patients

with

severe

renal

impairment

Cl

cr

mLminute

who

are

years

of

age

mgkg

once

daily

not

to

exceed

mg

per

dose

for

the

first

doses

no

initial

direct

IV

dose

with

concurrent

aspirin

therapy

mg

daily

Geriatric

Patients

Use

with

caution

careful

attention

to

dosing

intervals

and

concomitant

medications

particularly

antiplatelet

drugs

advised

Manufacturer

states

that

no

dosage

adjustment

necessary

in

geriatric

patients

for

uses

other

than

STEMI

unless

renal

function

is

impaired

Patients

years

of

age

with

STEMI

mgkg

subQ

every

hours

maximum

dose

mg

for

each

of

the

first

doses

only

then

mgkg

per

dose

thereafter

do

not

administer

an

initial

direct

IV

dose

Give

in

conjunction

with

aspirin

therapy

unless

contraindicated

LowWeight

Patients

Carefully

monitor

for

signs

and

symptoms

of

bleeding

in

patients

with

low

body

weight

women

kg

or

men

kg

Obese

Patients

Safety

and

efficacy

of

thromboprophylactic

doses

in

patients

with

body

mass

index

BMI

kgm

not

established

closely

monitor

for

signs

and

symptoms

of

thromboembolism

in

such

patients

Cautions

for

Enoxaparin

Sodium

Contraindications

Active

major

bleeding

Thrombocytopenia

associated

with

a

positive

in

vitro

test

for

antiplatelet

antibody

in

the

presence

of

the

drug

Known

hypersensitivity

to

enoxaparin

sodium

eg

pruritus

urticaria

anaphylacticanaphylactoid

reactions

heparin

pork

products

benzyl

alcohol

or

any

ingredient

in

the

formulation

WarningsPrecautions

SpinalEpidural

Hematomas

Epidural

or

spinal

hematoma

reported

with

concurrent

use

of

anticoagulants

eg

LMWHs

heparinoids

and

neuraxial

spinalepidural

anesthesia

or

spinal

puncture

procedures

Such

hematomas

have

resulted

in

neurologic

injury

including

longterm

or

permanent

paralysis

See

Boxed

Warning

Prior

to

performing

a

spinal

or

epidural

procedure

determine

whether

a

patient

is

receiving

anticoagulants

Carefully

consider

the

timing

of

spinal

catheter

placement

and

removal

in

relation

to

anticoagulant

use

considering

both

dosage

and

pharmacokinetic

properties

eg

elimination

halflife

of

the

anticoagulant

Insertion

or

removal

of

catheter

is

best

performed

when

the

anticoagulant

effect

of

enoxaparin

is

minimal

eg

at

least

hours

after

a

low

dose

mg

once

or

twice

daily

or

mg

once

daily

or

at

least

hours

after

a

high

dose

mgkg

twice

daily

mgkg

twice

daily

or

mgkg

once

daily

In

patients

receiving

a

twicedaily

treatment

dosage

or

mgkg

twice

daily

omit

second

dose

to

allow

for

a

longer

delay

between

doses

Consider

doubling

these

recommended

time

delays

in

patients

with

renal

impairment

Consider

delaying

subsequent

dose

of

enoxaparin

for

at

least

hours

after

catheter

removal

based

on

patients

risk

of

bleeding

versus

thrombosis

Frequently

monitor

for

signs

of

neurologic

impairment

eg

midline

back

pain

numbness

or

weakness

in

lower

limbs

bowel

or

bladder

dysfunction

If

spinal

hematoma

suspected

diagnose

and

treat

immediately

consider

spinal

cord

decompression

even

though

it

may

not

prevent

or

reverse

neurologic

sequelae

Other

Warnings

Related

to

Hemorrhage

As

with

other

anticoagulants

bleeding

may

occur

at

any

site

during

therapy

Major

sometimes

fatal

hemorrhages

including

retroperitoneal

and

intracranial

bleeding

have

been

reported

Search

for

bleeding

site

if

an

unexplained

decrease

in

hematocrit

or

BP

occurs

Use

with

extreme

caution

in

patients

with

an

increased

risk

of

hemorrhage

Such

patients

include

those

with

bacterial

endocarditis

congenital

or

acquired

bleeding

disorders

active

ulceration

and

angiodysplastic

GI

disease

hemorrhagic

stroke

or

recent

brain

spinal

or

ophthalmologic

surgery

Increased

risk

for

hemorrhage

in

patients

treated

concomitantly

with

platelet

inhibitors

Use

with

caution

in

patients

with

bleeding

diathesis

uncontrolled

arterial

hypertension

or

a

history

of

recent

GI

ulceration

diabetic

retinopathy

renal

dysfunction

or

hemorrhage

Periodic

CBCs

including

platelet

counts

and

stool

occult

blood

tests

recommended

If

abnormal

coagulation

parameters

or

bleeding

occurs

may

use

antifactor

Xa

levels

to

monitor

anticoagulant

effects

of

enoxaparin

Carefully

monitor

patients

with

low

body

weight

or

renal

impairment

for

signs

and

symptoms

of

bleeding

Women

treated

with

an

LMWH

with

or

without

a

GP

IIbIIIareceptor

inhibitor

prior

to

PCI

appear

to

experience

more

bleeding

complications

than

do

men

If

enoxaparin

overdosage

occurs

protamine

sulfate

may

be

administered

Because

fatal

reactions

resembling

anaphylaxis

have

been

reported

with

protamine

sulfate

administration

use

only

when

resuscitation

techniques

and

treatment

for

anaphylactic

shock

are

readily

available

To

minimize

risk

of

bleeding

during

percutaneous

revascularization

procedures

adhere

precisely

to

recommended

dosing

intervals

Ensure

hemostasis

at

puncture

site

after

PCI

observe

for

signs

of

bleeding

or

hematoma

formation

If

arterial

closure

device

used

may

remove

sheath

immediately

if

manual

compression

used

remove

sheath

hours

after

last

dose

of

enoxaparin

Administer

next

scheduled

dose

no

sooner

than

hours

after

sheath

removal

Thrombocytopenia

Cases

of

HIT

with

thrombosis

reported

including

complications

such

as

organ

infarction

limb

ischemia

or

death

Use

with

extreme

caution

in

patients

with

a

history

of

HIT

Monitor

thrombocytopenia

of

any

degree

closely

If

platelet

count

falls

to

discontinue

enoxaparin

Interchangeability

with

Other

Heparins

Can

not

use

enoxaparin

sodium

interchangeably

with

other

LMWHs

or

heparin

sodium

because

of

differences

in

manufacturing

process

molecular

weight

distribution

antifactor

Xa

and

antifactor

II

a

activities

dosage

units

and

dosage

See

Dosage

under

Dosage

and

Administration

Patients

with

Mechanical

Prosthetic

Heart

Valves

Valve

thrombosis

that

resulted

in

death

andor

required

surgical

intervention

reported

during

prophylaxis

in

some

patients

with

mechanical

prosthetic

heart

valves

including

pregnant

women

Women

with

mechanical

prosthetic

heart

valves

are

at

higher

risk

for

thromboembolism

during

pregnancy

If

enoxaparin

is

used

in

pregnant

women

with

mechanical

prosthetic

heart

valves

monitor

peak

and

trough

antifactor

Xa

concentrations

frequently

and

adjust

dosage

if

necessary

to

maintain

antifactor

Xa

levels

of

unitsmL

hours

after

dosing

Specific

Populations

Pregnancy

Category

B

Because

benzyl

alcohol

may

cross

the

placenta

enoxaparin

in

multipledose

vials

containing

benzyl

alcohol

should

be

used

with

caution

and

only

if

clearly

needed

in

pregnant

women

Maternal

and

neonatal

hemorrhage

has

occurred

potentially

fatal

Monitor

pregnant

women

carefully

for

evidence

of

bleeding

or

excessive

anticoagulation

As

delivery

approaches

consider

use

of

a

shorteracting

anticoagulant

See

Boxed

Warning

Lactation

Not

known

whether

enoxaparin

is

distributed

into

breast

milk

Discontinue

nursing

or

the

drug

ACCP

recommends

that

LMWHs

be

continued

in

nursing

women

who

are

already

receiving

such

therapy

Pediatric

Use

Safety

and

efficacy

not

established

Large

amounts

of

benzyl

alcohol

ie

mgkg

daily

has

been

associated

with

toxicity

in

neonates

each

mL

of

enoxaparin

sodium

injection

in

multipledose

vials

contains

mg

of

benzyl

alcohol

as

a

preservative

Geriatric

Use

Use

with

caution

No

substantial

differences

in

efficacy

relative

to

younger

adults

Possible

increased

risk

of

bleeding

complications

Pay

careful

attention

to

dosing

intervals

and

concomitant

medications

especially

antiplatelet

medications

Consider

monitoring

ie

with

antifactor

Xa

assay

geriatric

patients

with

low

body

weight

kg

and

those

predisposed

to

decreased

renal

function

Renal

Impairment

Use

with

caution

carefully

monitor

for

manifestations

of

bleeding

Monitor

antifactor

Xa

concentrations

in

patients

with

appreciable

renal

impairment

Hyperkalemia

reported

in

patients

with

renal

failure

receiving

enoxaparin

Decreased

clearance

Dosage

adjustments

necessary

in

patients

with

severe

renal

impairment

See

Renal

Impairment

under

Dosage

and

Administration

Common

Adverse

Effects

Elevated

serum

AST

ALT

concentrations

hemorrhage

including

at

injection

site

anemia

fever

peripheral

edema

Interactions

for

Enoxaparin

Sodium

Drugs

Affecting

Hemostasis

Potential

pharmacodynamic

interaction

with

concomitant

use

of

anticoagulants

plateletaggregation

inhibitors

or

other

drugs

affecting

hemostasis

increased

risk

of

bleeding

complications

Use

with

caution

Specific

Drugs

Drug

Interaction

Comments

Anticoagulants

Increased

risk

of

bleeding

No

pharmacokinetic

interaction

noted

with

concomitant

administration

of

thrombolytic

agents

If

possible

discontinue

other

anticoagulants

prior

to

initiating

enoxaparin

If

concomitant

use

is

essential

careful

clinical

and

laboratory

monitoring

advised

Aspirin

Increased

risk

of

bleeding

If

possible

discontinue

aspirin

prior

to

initiating

enoxaparin

If

concomitant

use

is

essential

careful

clinical

and

laboratory

monitoring

advised

NSAIAs

eg

ketorolac

tromethamine

Increased

risk

of

bleeding

If

possible

discontinue

NSAIAs

prior

to

initiating

enoxaparin

If

concomitant

use

is

essential

careful

clinical

and

laboratory

monitoring

advised

Dipyridamole

Increased

risk

of

bleeding

If

possible

discontinue

dipyridamole

prior

to

initiating

enoxaparin

If

concomitant

use

is

essential

careful

clinical

and

laboratory

monitoring

advised

Salicylates

Increased

risk

of

bleeding

If

possible

discontinue

salicylates

prior

to

initiating

enoxaparin

If

concomitant

use

is

essential

careful

clinical

and

laboratory

monitoring

advised

Sulfinpyrazone

Increased

risk

of

bleeding

If

possible

discontinue

sulfinpyrazone

prior

to

initiating

enoxaparin

If

concomitant

use

is

essential

careful

clinical

and

laboratory

monitoring

advised

Enoxaparin

Sodium

Pharmacokinetics

Absorption

Bioavailability

Mean

absolute

bioavailability

of

approximately

based

on

antifactor

Xa

activity

when

given

subQ

in

healthy

individuals

Onset

Maximum

antifactor

Xa

and

antithrombin

antifactor

II

a

activities

occur

hours

after

administration

Direct

IV

injection

of

mg

immediately

followed

by

mgkg

dose

subQ

resulted

in

postinjection

aPTT

of

seconds

Duration

Substantial

antifactor

Xa

activity

persists

in

plasma

for

about

hours

following

administration

mg

once

daily

Average

aPTT

prolongation

on

day

about

higher

than

on

day

Distribution

Extent

About

L

based

on

antifactor

Xa

activity

Enoxaparin

does

not

appear

to

cross

the

placenta

not

known

whether

the

drug

is

distributed

into

milk

Elimination

Metabolism

Metabolized

principally

in

the

liver

via

desulfation

andor

depolymerization

to

less

active

metabolites

Elimination

Route

of

dose

is

excreted

in

urine

Halflife

hours

after

single

subQ

dose

approximately

hours

after

multiple

dosing

based

on

antifactor

Xa

activity

Special

Populations

Clearance

reduced

in

patients

with

renal

impairment

In

patients

with

severe

renal

impairment

Cl

cr

mLminute

antifactor

Xa

exposure

represented

by

AUC

was

increased

by

approximately

Possible

delayed

elimination

and

increased

exposure

in

geriatric

patients

Stability

Storage

Parenteral

Solution

for

Injection

may

be

exposed

to

Compatibility

For

information

on

systemic

interactions

resulting

from

concomitant

use

see

Interactions

Parenteral

Solution

Compatibility

HID

Compatible

Sodium

chloride

Actions

Has

less

effect

than

heparin

on

thrombin

at

a

given

level

of

antifactor

Xa

activity

Prolongs

some

global

clotting

function

tests

ie

thrombin

time

activated

partial

thromboplastin

time

aPTT

by

up

to

times

the

control

value

At

a

recommended

dosage

in

a

large

clinical

trial

the

aPTT

was

seconds

in

most

treated

patients

Advice

to

Patients

Importance

of

advising

patients

who

have

had

neuraxial

anesthesia

or

spinal

puncture

to

monitor

for

manifestations

of

spinal

or

epidural

hematoma

eg

tingling

or

numbness

in

lower

limbs

muscle

weakness

particularly

if

they

are

receiving

concomitant

NSAIAs

plateletaggregation

inhibitors

eg

clopidogrel

or

other

anticoagulants

importance

of

immediately

contacting

a

clinician

if

any

of

these

symptoms

occur

If

therapy

is

to

continue

after

hospital

discharge

importance

of

instructing

patient

on

proper

injection

technique

of

enoxaparin

Importance

of

informing

patients

that

they

may

bruise

andor

bleed

more

easily

and

that

a

longer

than

normal

time

may

be

required

to

stop

bleeding

when

taking

enoxaparin

Importance

of

patients

reporting

any

unusual

bleeding

bruising

or

signs

of

thrombocytopenia

eg

dark

red

spots

under

skin

to

clinician

Importance

of

patients

informing

clinicians

including

dentists

that

they

are

receiving

enoxaparin

therapy

before

scheduling

any

invasive

procedures

Importance

of

informing

clinicians

of

existing

or

contemplated

concomitant

therapy

including

prescription

and

OTC

drugs

Importance

of

women

informing

clinicians

if

they

are

or

plan

to

become

pregnant

or

plan

to

breastfeed

Importance

of

informing

patients

of

other

important

precautionary

information

See

Cautions

Preparations

Excipients

in

commercially

available

drug

preparations

may

have

clinically

important

effects

in

some

individuals

consult

specific

product

labeling

for

details

Please

refer

to

the

ASHP

Drug

Shortages

Resource

Center

for

information

on

shortages

of

one

or

more

of

these

preparations

available

from

one

or

more

manufacturer

distributor

andor

repackager

by

generic

nonproprietary

name

Enoxaparin

Sodium

Porcine

Routes

Dosage

Forms

Strengths

Brand

Names

Manufacturer

Parenteral

Injection

for

subcutaneous

use

mL

and

mg

Enoxaparin

Sodium

Injection

Lovenox

available

as

prefilled

disposable

syringes

SanofiAventis

mL

and

mg

Enoxaparin

Sodium

Injection

Lovenox

available

as

disposable

prefilled

syringes

SanofiAventis

mL

Enoxaparin

Sodium

Injection

Lovenox

SanofiAventis

AHFS

DI

Essentials

Copyright

Selected

Revisions

October

American

Society

of

HealthSystem

Pharmacists

Inc

EastWest

Highway

Suite

Bethesda

Maryland

Use

is

not

currently

included

in

the

labeling

approved

by

the

US

Food

and

Drug

Administration

References

SanofiAventis

US

Lovenox

enoxaparin

sodium

injection

prescribing

information

Bridgewater

NJ

Oct

Buckley

MM

Sorkin

EM

Enoxaparin

A

review

of

its

pharmacology

and

clinical

applications

in

the

prevention

and

treatment

of

thromboembolic

disorders

Drugs

Turpie

A

Enoxaparin

prophylaxis

in

elective

hip

surgery

Acta

Chir

Scand

Suppl

Fareed

J

Walenga

JM

Lassen

M

et

al

Pharmacologic

profile

of

a

low

molecular

weight

heparin

enoxaparin

experimental

and

clinical

validation

of

the

prophylactic

antithrombotic

effects

Acta

Chir

Scand

Suppl

Hirsh

J

From

unfractionated

heparins

to

low

molecular

weight

heparins

Acta

Chir

Scand

Suppl

Planes

A

Vochelle

N

Fagola

M

et

al

Oncedaily

dosing

of

enoxaparin

a

low

molecular

weight

heparin

in

prevention

of

deepvein

thrombosis

after

total

hip

replacement

Acta

Chir

Scand

Suppl

Planes

A

Vochelle

N

Mazas

F

et

al

Prevention

of

postoperative

venous

thrombosis

a

randomized

trial

comparing

unfractionated

heparin

with

low

molecular

weight

heparin

in

patients

undergoing

total

hip

replacement

Thromb

Haemost

Levine

MN

Hirsh

J

Gent

M

et

al

Prevention

of

deepvein

thrombosis

after

elective

hip

surgery

A

randomized

trial

comparing

low

molecular

weight

heparin

with

standard

unfractionated

heparin

Ann

Intern

Med

Haas

S

Flosbach

CW

Prevention

of

postoperative

thromboembolism

in

general

surgery

with

enoxaparin

preliminary

findings

Acta

Chir

Scand

Suppl

Spiro

TE

Enoxaparin

Clinical

Trial

Group

A

randomized

trial

of

enoxaparin

administered

post

operatively

for

the

prevention

of

deepvein

thrombosis

following

elective

hip

replacement

surgery

Thromb

Haemost

Griffiths

MC

ed

USAN

USAN

and

the

USP

dictionary

of

drug

names

Rockville

MD

The

United

States

Pharmacopeial

Convention

Inc

Bara

L

Samama

M

Pharmacokinetics

of

low

molecular

weight

heparins

Acta

Chir

Scand

Suppl

Fareed

J

Walenga

JM

Hoppensteadt

D

et

al

Biochemical

and

pharmacologic

inequivalence

of

low

molecular

weight

heparins

Ann

N

Y

Acad

Sci

Hoppensteadt

D

Racanelli

A

Walenga

JM

et

al

Comparative

antithrombotic

and

hemorrhagic

effects

of

dermatan

sulfate

heparan

sulfate

and

heparin

Semin

Thromb

Hemost

Fareed

J

Walenga

JM

Hoppensteadt

D

et

al

Chemical

and

biological

heterogeneity

in

low

molecular

weight

heparins

implications

for

clinical

use

and

standardization

Semin

Thromb

Hemost

Fareed

J

Walenga

JM

Williamson

K

et

al

Studies

on

the

antithrombotic

effects

and

pharmacokinetics

of

heparin

fractions

and

fragments

Semin

Thromb

Hemost

RhônePoulenc

Rorer

Collegeville

PA

Personal

communication

Spiro

TE

Colwell

CW

Trowbridge

AA

for

the

Enoxaparin

Clinical

Trial

Group

A

clinical

trial

comparing

the

efficacy

and

safety

of

enoxaparin

a

low

molecular

weight

heparin

and

unfractionated

heparin

for

the

prevention

of

deep

venous

thrombosis

after

elective

hip

replacement

surgery

Imperiale

TF

Speroff

T

A

metaanlysis

of

methods

to

prevent

venous

thromboembolism

following

total

hip

replacement

JAMA

Ledere

JR

Geerts

WH

Desjardins

L

et

al

Prevention

of

deepvein

thrombosis

after

major

knee

surgerya

randomized

doubleblind

trial

comparing

a

low

molecular

weight

heparin

fragment

enoxaparin

to

placebo

Thromb

Haemost

Spiro

TE

Colwell

CW

Bona

RD

et

al

et

al

Enoxaparin

versus

unfractionated

heparin

for

prevention

of

venous

thromboembolic

disease

after

elective

knee

replacement

surgery

Chest

Noble

S

Peters

DH

Goa

KL

Enoxaparin

a

reappraisal

of

its

pharmacology

and

clinical

applications

in

the

prevention

and

treatment

of

thromboembolic

disease

Drugs

Heit

JA

Berkowitz

SD

Bona

R

et

al

Efficacy

and

safety

of

low

molecular

weight

heparin

ardeparin

sodium

compared

to

warfarin

for

the

prevention

of

venous

thromboembolism

after

total

knee

replacement

surgery

a

doubleblind

doseranging

study

Thromb

Haemost

Hull

R

Raskob

G

Pineo

G

et

al

A

comparison

of

subcutaneous

lowmolecular

weight

heparin

with

warfarin

sodium

for

prophylaxis

against

deepvein

thrombosis

after

hip

or

knee

implantation

N

Engl

J

Med

Lumpkin

MM

Dear

health

care

professional

letter

regarding

reports

of

epidural

or

spinal

hematomas

with

concurrent

use

of

low

molecular

weight

heparins

or

heparinoids

and

spinalepidural

anesthesia

or

spinal

puncture

Rockville

MD

US

Food

and

Drug

Administration

Dec

ENOXACAN

Study

Group

Efficacy

of

enoxaparin

versus

unfractionated

heparin

for

prevention

of

deepvein

thrombosis

in

elective

cancer

surgery

a

doubleblind

randomized

multicentre

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EvidenceBased

Guidelines

Third

Edition

Reg

Anesth

Pain

Med

JanFeb

Gibbons

RJ

Fuster

V

Therapy

for

patients

with

acute

coronary

syndromesnew

opportunities

N

Engl

J

Med

Editorial

Morrow

DA

Antman

EM

Fox

KAA

et

al

Oneyear

outcomes

after

a

strategy

using

enoxaparin

vs

unfractionated

heparin

in

patients

undergoing

fibrinolysis

for

STsegment

elevation

myocardial

infarction

results

of

the

ExTRACTTIMI

Trial

Eur

Heart

J

SanofiAventis

Bridgewater

NJ

Personal

communication

Gibson

CM

Murphy

SA

Montalescot

G

et

al

Percutaneous

coronary

intervention

in

patients

receiving

enoxaparin

or

unfractionated

heparin

after

fibrinolytic

therapy

for

STsegment

elevation

myocardial

infarction

in

the

ExTRACTTIMI

trial

J

Am

Coll

Cardiol

OGara

PT

Kushner

FG

Ascheim

DD

et

al

ACCFAHA

guideline

for

the

management

of

STelevation

myocardial

infarction

a

report

of

the

American

College

of

Cardiology

FoundationAmerican

Heart

Association

Task

Force

on

Practice

Guidelines

Circulation

Reed

GW

Rossi

JE

Cannon

CP

Acute

myocardial

infarction

Lancet

Anderson

JL

Adams

CD

Antman

EM

et

al

ACCFAHA

Focused

Update

Incorporated

Into

the

ACCAHA

Guidelines

for

the

Management

of

Patients

With

Unstable

AnginaNonSTElevation

Myocardial

Infarction

a

report

of

the

American

College

of

Cardiology

FoundationAmerican

Heart

Association

Task

Force

on

Practice

Guidelines

Circulation

Levine

GN

Bates

ER

Blankenship

JC

et

al

ACCFAHASCAI

Guideline

for

Percutaneous

Coronary

Intervention

A

report

of

the

American

College

of

Cardiology

FoundationAmerican

Heart

Association

Task

Force

on

Practice

Guidelines

and

the

Society

for

Cardiovascular

Angiography

and

Interventions

J

Am

Coll

Cardiol

Bonow

RO

Carabello

BA

Chatterjee

K

et

al

Focused

update

incorporated

into

the

ACCAHA

guidelines

for

the

management

of

patients

with

valvular

heart

disease

a

report

of

the

American

College

of

CardiologyAmerican

Heart

Association

Task

Force

on

Practice

Guidelines

Writing

Committee

to

Revise

the

Guidelines

for

the

Management

of

Patients

With

Valvular

Heart

Disease

endorsed

by

the

Society

of

Cardiovascular

Anesthesiologists

Society

for

Cardiovascular

Angiography

and

Interventions

and

Society

of

Thoracic

Surgeons

Circulation

Fuster

V

Rydén

LE

Cannom

DS

et

al

ACCFAHAHRS

focused

updates

incorporated

into

the

ACCAHAESC

guidelines

for

the

management

of

patients

with

atrial

fibrillation

a

report

of

the

American

College

of

Cardiology

FoundationAmerican

Heart

Association

Task

Force

on

practice

guidelines

Circulation

Holbrook

A

Schulman

S

Witt

DM

et

al

Evidencebased

management

of

anticoagulant

therapy

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

Kahn

SR

Lim

W

Dunn

AS

et

al

Prevention

of

VTE

in

nonsurgical

patients

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

Gould

MK

Garcia

DA

Wren

SM

et

al

Prevention

of

VTE

in

nonorthopedic

surgical

patients

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

FalckYtter

Y

Francis

CW

Johanson

et

al

Prevention

of

VTE

in

orthopedic

surgery

patients

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

Douketis

JD

Spyropoulos

AC

Spencer

FA

et

al

Perioperative

management

of

antithrombotic

therapy

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

Kearon

C

Akl

EA

Comerota

AJ

et

al

Antithrombotic

therapy

for

VTE

disease

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

Linkins

LA

Dans

AL

Moores

LK

et

al

Treatment

and

prevention

of

heparininduced

thrombocytopenia

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

You

JJ

Singer

DE

Howard

PA

et

al

Antithrombotic

therapy

for

atrial

fibrillation

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

Whitlock

RP

Sun

JC

Fremes

SE

et

al

Antithrombotic

and

thrombolytic

therapy

for

valvular

disease

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

Lansberg

MG

ODonnell

MJ

Khatri

P

et

al

Antithrombotic

and

thrombolytic

therapy

for

ischemic

stroke

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

Bates

SM

Greer

IA

Middeldorp

S

et

al

VTE

thrombophilia

antithrombotic

therapy

and

pregnancy

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

Monagle

P

Chan

AK

Goldenberg

et

al

Antithrombotic

therapy

in

neonates

and

children

Antithrombotic

Therapy

and

Prevention

of

Thrombosis

ed

American

College

of

Chest

Physicians

EvidenceBased

Clinical

Practice

Guidelines

Chest

Bushnell

C

McCullough

LD

Awad

IA

et

al

on

behalf

of

the

American

Heart

Association

Stroke

Council

Council

on

Cardiovascular

and

Stroke

Nursing

Council

on

Clinical

Cardiology

Council

on

Epidemiology

and

Prevention

and

Council

for

High

Blood

Pressure

Research

Guidelines

for

the

prevention

of

stroke

in

women

a

statement

for

healthcare

professionals

from

the

American

Heart

AssociationAmerican

Stroke

Association

Stroke

Amsterdam

EA

Wenger

NK

Brindis

RG

et

al

AHAACC

guideline

for

the

management

of

patients

with

nonSTelevation

acute

coronary

syndromes

a

report

of

the

American

College

of

CardiologyAmerican

Heart

Association

Task

Force

on

Practice

Guidelines

Circulation

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