What is the recommended dose of Lovenox (enoxaparin) for treating pulmonary embolism?

Lovenox (Enoxaparin) Dosing for Pulmonary Embolism

For treating pulmonary embolism, the recommended dose of Lovenox (enoxaparin) is 1 mg/kg subcutaneously every 12 hours. 1

Standard Dosing Regimen

Enoxaparin dosing for pulmonary embolism follows these evidence-based guidelines:

• Initial treatment dose: 1 mg/kg subcutaneously every 12 hours 1
• Alternative regimen: 1.5 mg/kg subcutaneously once daily (approved in the US and some European countries for inpatient treatment) 1
• Duration: Minimum 5 days and until adequate oral anticoagulation is established (INR 2.0-3.0 for at least two consecutive days) when transitioning to vitamin K antagonists 1

Special Populations and Considerations

Cancer Patients

• For cancer patients with PE, enoxaparin 1 mg/kg every 12 hours is recommended 1
• Note that dalteparin has the highest quality evidence for cancer-associated VTE (Category 1 recommendation) 1

Obesity

• For patients with BMI ≥40 kg/m²:
  • Consider weight-based dosing of 0.8-1.0 mg/kg every 12 hours 1
  • Anti-Xa monitoring may be beneficial

Renal Impairment

• For severe renal insufficiency (CrCl <30 mL/min):
  • Dose adjustment is required for enoxaparin
  • Consider unfractionated heparin as an alternative 1
  • Monitor anti-Xa levels if using enoxaparin

Pregnancy

• Standard prophylactic dose: 40 mg subcutaneously once daily
• For class III obesity in pregnancy: Consider intermediate doses (40 mg subcutaneously every 12 hours) 1

Monitoring Parameters

• Platelet count monitoring is recommended during the first 14 days of treatment due to risk of heparin-induced thrombocytopenia (HIT) 1
• Anti-Xa monitoring is not routinely required but should be considered in:
  • Severe renal impairment
  • Pregnancy
  • Extreme body weights
  • Prolonged therapy

Transition to Oral Anticoagulation

When transitioning to a vitamin K antagonist (e.g., warfarin):

• Start oral anticoagulant as soon as possible, preferably on the same day as enoxaparin 1
• Continue enoxaparin for at least 5 days and until INR is 2.0-3.0 for two consecutive days 1

Common Pitfalls to Avoid

1. Underdosing in obesity: Standard fixed doses may be inadequate in obese patients
2. Failure to adjust for renal impairment: Enoxaparin accumulates in renal failure
3. Inadequate duration: Stopping enoxaparin too early before therapeutic oral anticoagulation is established
4. Missing HIT: Failure to monitor platelet counts during treatment
5. Improper administration: Enoxaparin should be injected into abdominal subcutaneous tissue

Alternative Anticoagulants

If enoxaparin is contraindicated or unavailable, consider:

• Unfractionated heparin: 80 units/kg IV bolus, then 18 units/kg/hour IV infusion, adjusted to aPTT 1.5-2.5× control 1
• Fondaparinux: Weight-based dosing (5 mg if <50 kg, 7.5 mg if 50-100 kg, 10 mg if >100 kg) subcutaneously once daily 1
• Direct oral anticoagulants (after initial parenteral anticoagulation) 1

The evidence strongly supports enoxaparin as an effective treatment for pulmonary embolism with comparable efficacy to unfractionated heparin but with advantages of fixed dosing, less monitoring, and subcutaneous administration 2.