What is the dose of Lovenox (enoxaparin) for patients on chronic anticoagulation with Eliquis (apixaban) who cannot take oral medications in the hospital?

Dosing of Enoxaparin for Patients on Chronic Apixaban Who Cannot Take Oral Medications

For patients on chronic anticoagulation with Eliquis (apixaban) who cannot take oral medications in the hospital, the recommended dose of Lovenox (enoxaparin) is 1 mg/kg subcutaneously every 12 hours, with dose adjustments based on age and renal function. 1

Standard Dosing Regimen

• Standard dose: 1 mg/kg SC every 12 hours 1
• For patients ≥75 years: 0.75 mg/kg SC every 12 hours (without an initial IV bolus) 1
• For patients with renal impairment (CrCl <30 mL/min): 1 mg/kg SC once daily 1

Special Considerations

Renal Function

• Always calculate creatinine clearance before initiating enoxaparin therapy
• For severe renal impairment, consider unfractionated heparin as an alternative 1

Weight-Based Adjustments

• For patients with BMI ≥40 kg/m², consider 0.8 mg/kg SC every 12 hours 1
• No dose should exceed 100 mg for the first two subcutaneous doses 2, 3

Initial IV Bolus Option

• In acute coronary syndrome settings, an initial IV bolus of 30 mg may be considered before starting the subcutaneous regimen 1
• This bolus is typically omitted in elderly patients (≥75 years) 1

Transitioning Between Anticoagulants

When transitioning from apixaban to enoxaparin:

1. Immediate transition: Start enoxaparin at the next scheduled apixaban dose time
2. No overlap period required: Unlike warfarin transitions, no overlap is needed between apixaban and enoxaparin 1
3. No loading dose needed: Standard dosing can be initiated without a loading dose when switching from apixaban 4

Monitoring Recommendations

• Routine anti-Xa level monitoring is not required for most patients
• Consider monitoring in:
  • Patients with severe renal impairment
  • Extremely low or high body weight
  • Prolonged therapy (>5 days)

Common Pitfalls to Avoid

1. Avoid switching between enoxaparin and unfractionated heparin during the same treatment course due to increased bleeding risk 1

2. Do not administer the first dose of enoxaparin too soon after the last dose of apixaban (ideally wait 12-24 hours)

3. Do not forget to reduce the dose in elderly patients or those with renal impairment

4. Avoid concomitant use of other medications that increase bleeding risk when possible (NSAIDs, antiplatelet agents)

5. Do not continue the same dose when transitioning back to oral apixaban once the patient can take oral medications

By following these dosing guidelines, you can safely manage anticoagulation in patients who are on chronic apixaban therapy but temporarily unable to take oral medications.