From the Guidelines
For patients with Acute Coronary Syndrome (ACS) and impaired renal function, the recommended dose of enoxaparin is 1 mg/kg subcutaneously once daily, rather than the standard twice-daily regimen used in patients with normal renal function, as stated in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes 1.
Key Considerations
- The dose reduction is necessary because enoxaparin is primarily eliminated by the kidneys, and impaired renal function leads to drug accumulation and increased bleeding risk.
- Treatment duration typically ranges from 2-8 days, or until hospital discharge or revascularization procedure, whichever comes first.
- Renal function should be monitored regularly during treatment, as drug accumulation can occur in these patients.
- Before initiating therapy, baseline complete blood count and renal function tests should be obtained.
- Regular monitoring of anti-Factor Xa levels may be beneficial in patients with severe renal impairment to avoid excessive anticoagulation.
Monitoring and Precautions
- Patients should also be monitored for signs of bleeding, and concomitant use of other antiplatelet or anticoagulant medications should be carefully evaluated to minimize bleeding complications.
- The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline also provides recommendations for other anticoagulants, such as UFH, bivalirudin, and fondaparinux, which may be considered in patients with ACS and impaired renal function 1.
Clinical Context
- The management of patients with ACS and impaired renal function requires careful consideration of the risks and benefits of anticoagulant therapy, as well as close monitoring of renal function and bleeding risk.
- The use of enoxaparin in patients with ACS and impaired renal function is supported by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes, which recommends a dose reduction to 1 mg/kg subcutaneously once daily in patients with creatinine clearance <30 mL/min 1.
From the Research
Enoxaparin Dosing for Acute Coronary Syndrome (ACS)
The recommended dose of enoxaparin for patients with Acute Coronary Syndrome (ACS) is 1 mg/kg administered subcutaneously every 12 hours 2.
Treatment Duration
The treatment duration of enoxaparin for patients with ACS is typically until the patient is clinically stable, but the exact duration may vary depending on the individual patient's condition and the treating physician's discretion 3.
Impaired Renal Function
For patients with impaired renal function, the dose of enoxaparin may need to be adjusted. However, according to the STEEPLE trial, enoxaparin can be administered safely without dose adjustment in patients with renal impairment undergoing percutaneous coronary intervention 4.
Key Considerations
- Enoxaparin dosing practices and risk factors for bleeding in patients with ACS have been studied, and it has been found that increasing patient age, coadministered nonsteroidal anti-inflammatory or antiplatelet drug therapy, and number of enoxaparin doses are risk factors for bleeding 2.
- The use of enoxaparin in patients with ACS has been compared to other anticoagulants, such as unfractionated heparin and fondaparinux, and has been found to have similar efficacy and safety profiles 3, 5.
- The diagnosis and treatment of ACS, including the use of enoxaparin, have been reviewed, and it has been found that prompt invasive coronary angiography and percutaneous or surgical revascularization are associated with a reduction in death and myocardial infarction 6.
Dosing Recommendations
- The dose of enoxaparin for patients with ACS and impaired renal function is 1 mg/kg administered subcutaneously every 12 hours, but may need to be adjusted based on individual patient factors 4, 2.
- The treatment duration of enoxaparin for patients with ACS is typically until the patient is clinically stable, but may vary depending on individual patient factors 3, 6.