From the Guidelines
Lovenox (enoxaparin) is recommended as a first-line treatment for pulmonary embolism (PE) due to its efficacy and safety profile, with a recommended dose of 1 mg/kg of body weight administered subcutaneously every 12 hours, or alternatively 1.5 mg/kg once daily, as supported by the 2020 ESC guidelines 1. When initiating anticoagulation for PE, it is crucial to start treatment without delay, even while diagnostic workup is in progress, especially in patients with high or intermediate clinical probability of PE 1. Key considerations for Lovenox treatment include:
- Monitoring renal function before starting treatment, as dose adjustments are necessary for patients with severe kidney impairment
- Common side effects such as bleeding, bruising at injection sites, and rarely, thrombocytopenia
- Teaching patients proper self-injection technique if they will be continuing treatment at home
- Overlapping with parenteral anticoagulation until an INR of 2.5 (range 2.0-3.0) is reached when transitioning to oral anticoagulation with a vitamin K antagonist (VKA) 1 The 2020 ESC guidelines also recommend that if anticoagulation is initiated parenterally, low molecular-weight heparin (LMWH) or fondaparinux is preferred over unfractionated heparin (UFH) for most patients 1. Additionally, when oral anticoagulation is started, a non-vitamin K antagonist oral anticoagulant (NOAC) is recommended in preference to a VKA for patients with PE who are eligible 1. It is essential to note that NOACs are not recommended in patients with severe renal impairment, during pregnancy and lactation, and in patients with antiphospholipid antibody syndrome 1. In terms of specific dosing, the 2008 guidelines provide detailed information on subcutaneous regimens of low molecular-weight heparins and fondaparinux approved for the treatment of pulmonary embolism, including enoxaparin 1.0 mg/kg every 12 hours or 1.5 mg/kg once daily 1.
From the Research
Lovenox (Enoxaparin) for Pulmonary Embolism
- Lovenox, also known as enoxaparin, is a low-molecular-weight heparin used to treat pulmonary embolism (PE) 2, 3, 4.
- The use of enoxaparin as monotherapy for symptomatic pulmonary embolism has been studied, with results showing it to be feasible and warranting further study in large clinical trials 2.
- Enoxaparin can be administered once or twice daily, with studies comparing the two regimens in cancer patients showing that once daily administration may be associated with a higher risk of recurrent PE and major bleeding 3.
- Enoxaparin is one of the currently approved drugs for the treatment of venous thromboembolism, including pulmonary embolism, and is often used in conjunction with other anticoagulants or as an alternative to warfarin 4.
Comparison with Direct Oral Anticoagulants (DOACs)
- Direct oral anticoagulants (DOACs) are now recommended as the first therapeutic choice for the treatment of pulmonary embolism, including in patients with renal impairment, liver impairment, and cancer 5.
- DOACs have been shown to be effective alternatives to traditional anticoagulation therapy, with fewer adverse effects, and are being used in various clinical scenarios, including outpatient management and early discharge from the emergency department 5.
- The use of DOACs has been proven to be safe and effective in special populations of PE patients, and additional research is contributing to identifying low-risk PE patients who can benefit from outpatient management or early discharge with DOAC treatment 5.