Lovenox Therapeutic Dose Chalk Talk

Eliquis failure: use lovenox or heparin to bridge to warfarin

If you want to switch between lovenox and heparin give heparin 12 hours after last lovenox was given as lovenox has a longer half life

If you want to switch from heparin to lovenox give lovenox within two hours of heparin gtt as heparin has a short half life.

Warfarin 10 or 5

Enoxaparin (Lovenox)—comes in prefilled syringes 30mg, 40mg, 60mg, 80mg, 100mg, 120mg, 150mg

Therapeutic enoxaparin = 1.5mg/kg/day or 1mg/kg/bid

Prophylactic enoxaparin = 40mg/day

Dose adjustment required/precaution advised for CrCl < 30mL/min

Dose adjustment required/precaution advised for obese patients with a BMI ≥ 40 kg/m2. Consider enoxaparin 0.75 mg/kg bid (therapeutic dosing) and enoxaparin 0.5 mg/kg (prophylactic dosing). Consider anti-Xa monitoring.

Round all enoxaparin doses to the nearest injection syringe availability. Do not have patients displace or “squirt out” some of the medication prior to administration

Dalteparin (Fragmin)—comes in prefilled syringes 2500units, 5000units, 7500units, 10,000units, 12,500units, 15,000units, 18,000units, 25,000units

Therapeutic dalteparin = 200units/kg/day

Prophylactic dalteparin = 2500-5000units/day

Dose adjustment required/precaution advised for CrCl < 30mL/min

5000 units/day may be reasonable for patients undergoing dialysis based on a study from 2010

 

Reference

Schmid P, Brodmann D, Fischer AG, Wuillemin WA. Prospective observational cohort study of bioaccumulation of dalteparin at a prophylactic dose in patients with peritoneal dialysis. J Thromb Haemost. 2010 Apr;8(4):850-2. Epub 2010 Jan 17.

Nutescu EA, Spinler SA, Wittkowsky A, Dager WE. Low-molecular-weight heparins in renal impairment and obesity: available evidence and clinical practice recommendations across medical and surgical settings. Ann Pharmacother. 2009;43(6):1064-83.

Lalama JT, Feeney ME, Vandiver JW, et al. Assessing an enoxaparin dosing in morbidly obese patients. J Thromb Thrombolysis. 2015; 39:516-521

In dialysis patients

Dialysis

Eliquis good data, advanced CKD patients, PE / DVT see them with eliquis

Xarelto no good data. Dailysis and advanced CKD Cr Cl < 25

lovenox Cr Cl < 15 15-30 1mg / kg once a day, ACS VTE above cr. clearance 1mg/kg BID, 1.5mg/kg once a day

heparin - given anywhere, kidney cr risk of bleeding

covid lovenox full dose lovenox everyone put on therapeutic dose lovenox

covid will affect kidneys, nobody will adjust the lovenox, cr will drop

retroperitoneal hemorrhage

AC - reversal

AP - DDAVP, qualitative defect,