From the Guidelines
Enoxaparin (Lovenox) should be used with caution in patients with end-stage renal disease (ESRD) for deep vein thrombosis (DVT) prophylaxis, with a recommended dose reduction to 30 mg once daily. For ESRD patients, this dose reduction is crucial due to the primary renal clearance of enoxaparin, which can lead to drug accumulation and increased bleeding risk when kidney function is severely impaired 1. The use of enoxaparin in ESRD patients requires careful consideration, as evidenced by a study suggesting that enoxaparin is associated with a 2- to 3-fold increased risk of bleeding when administered in standard, unadjusted therapeutic doses to patients with severe renal insufficiency compared with those without severe renal insufficiency 1.
Some key points to consider when using enoxaparin in ESRD patients include:
- Dose reduction: A reduced dose of 30 mg once daily is generally recommended for ESRD patients on hemodialysis, compared to the standard 40 mg once daily used in patients with normal renal function 1.
- Drug monitoring: Monitoring through anti-Factor Xa levels may be necessary when using enoxaparin in ESRD patients to ensure appropriate anticoagulation while minimizing bleeding risk.
- Alternative options: Unfractionated heparin at 5000 units subcutaneously two or three times daily may be preferred in ESRD patients due to its shorter half-life and clearance independent of kidney function.
- Recent guidelines: Current guidelines recommend LMWH, such as enoxaparin, as the first-line pharmacologic agent for VTE prophylaxis, but caution against its use in patients with significant renal dysfunction, defined as creatinine clearance of less than 30 mL/min 1.
Overall, the use of enoxaparin in ESRD patients for DVT prophylaxis requires careful consideration of the potential risks and benefits, and alternative options should be considered when possible.
From the Research
Lovenox for DVT Prophylaxis in Patients with ESRD
- The use of Lovenox (enoxaparin) for deep vein thrombosis (DVT) prophylaxis in patients with end-stage renal disease (ESRD) is a topic of concern due to the potential risk of bleeding 2, 3.
- A study published in Hospital Pharmacy found that the difference in major or clinically relevant non-major bleeding rates between enoxaparin and unfractionated heparin (UFH) was not statistically significant, but the 6.8% bleed rate with enoxaparin is concerning 2.
- Another study published in Pharmacotherapy found that enoxaparin was associated with an increased risk of major bleeding compared to UFH in critically ill patients with renal impairment 3.
- The American Family Physician recommends that patients with ESRD be monitored for signs of protein-energy wasting and malnutrition, and that controlling blood pressure in patients receiving dialysis can improve mortality 4.
- A study published in Chest found that both UFH and enoxaparin are associated with comparable increases in major bleeding complications in patients with renal dysfunction receiving full-dose anticoagulation therapy 5.
- A retrospective cohort study published in The Journal of International Medical Research found that enoxaparin 20 mg SC daily resulted in a 5.6% incidence of VTE, which is similar to the previously published acceptable incidence of VTE in patients with normal renal function receiving enoxaparin 40 mg SC daily 6.
Bleeding Risks
- Thrombocytopenia was associated with bleeding in patients with ESRD receiving enoxaparin 2.
- Age >75 years was significantly associated with an increased risk of bleeding in patients with renal failure receiving enoxaparin 20 mg SC daily 6.
- A creatinine clearance rate of 15 to 29 mL/minute was significantly associated with a lower risk of bleeding in patients with renal failure receiving enoxaparin 20 mg SC daily 6.