Is Lovenox (enoxaparin) okay for Deep Vein Thrombosis (DVT) prophylaxis in patients with stroke?

Lovenox for DVT Prophylaxis in Stroke Patients

Yes, Lovenox (enoxaparin) is recommended for DVT prophylaxis in patients with acute ischemic stroke who are at high risk of venous thromboembolism. 1

Risk Assessment for VTE in Stroke Patients

All stroke patients should be assessed for their risk of developing venous thromboembolism. High-risk factors include:

• Inability to move one or both lower limbs
• Inability to mobilize independently
• Previous history of venous thromboembolism
• Dehydration
• Comorbidities such as cancer 1

Evidence Supporting Lovenox Use

Efficacy

• The PREVAIL study demonstrated that enoxaparin 40 mg once daily was superior to unfractionated heparin (UFH) in preventing VTE in stroke patients, reducing the risk by 43% (10% vs 18%, relative risk 0.57) 2
• This benefit was consistent across stroke severity groups, including both severe strokes (NIHSS ≥14) and less severe strokes (NIHSS <14) 2
• Individual patient data meta-analysis showed enoxaparin reduced risk of total VTE by 37% and symptomatic VTE by 62% compared to UFH in hospitalized medical patients, with particular benefit in stroke patients (RR 0.59) 3

Safety

• The PREVAIL neurological outcomes subanalysis showed that enoxaparin did not lead to poorer long-term neurological outcomes or increased rates of symptomatic intracranial hemorrhage compared to UFH 4
• Major bleeding rates are consistently low and similar between enoxaparin and UFH 2, 3

Implementation Algorithm

1. Assess VTE risk in all stroke patients upon admission

2. For high-risk patients with ischemic stroke:

   • Start enoxaparin 40 mg subcutaneously once daily if no contraindications exist 1
   • Use unfractionated heparin for patients with renal failure 1

3. Timing considerations:

   • Begin immediately if there are no contraindications 1
   • For patients with hemorrhagic stroke, wait at least 48 hours after onset and obtain repeat brain imaging to confirm hematoma stability 1

4. Duration:

   • Continue until patient becomes independently mobile
   • For patients remaining immobile beyond 30 days, ongoing prophylaxis is recommended 1

Important Caveats and Considerations

• Contraindications: Systemic or intracranial hemorrhage 1
• Alternative approach: Intermittent pneumatic compression (IPC) devices are an alternative for patients who cannot receive pharmacological prophylaxis 1
• Avoid: Anti-embolism stockings alone are not recommended for post-stroke VTE prophylaxis 1
• Adjunctive measures: Early mobilization (between 24-48 hours after stroke onset) and adequate hydration should be encouraged for all acute stroke patients 1

Monitoring

• Monitor for signs of bleeding daily
• For patients with renal impairment, dose adjustment or use of unfractionated heparin may be necessary 1

The evidence strongly supports the use of Lovenox (enoxaparin) for DVT prophylaxis in stroke patients, with demonstrated superior efficacy to unfractionated heparin and a favorable safety profile.