Enoxaparin Dosing for DVT Prophylaxis in a 114kg Patient
For DVT prophylaxis in a 114kg patient, the recommended dose of enoxaparin is 40mg subcutaneously once daily.
Rationale for Dosing Recommendation
The recommended prophylactic dose of enoxaparin for DVT prevention is supported by multiple clinical practice guidelines:
- The American Society of Clinical Oncology (ASCO) guidelines specify that for hospitalized patients requiring DVT prophylaxis, enoxaparin should be dosed at 40mg once daily 1.
- The National Comprehensive Cancer Network (NCCN) guidelines similarly recommend enoxaparin 40mg once daily for DVT prophylaxis in hospitalized patients 1.
This standard prophylactic dose of 40mg once daily applies regardless of weight for most patients, including those with obesity. Unlike therapeutic dosing for established DVT/PE treatment (which uses weight-based dosing), prophylactic dosing generally uses fixed doses.
Special Considerations for Obese Patients
For patients with obesity, particularly those with BMI ≥40 kg/m² (class 3 obesity), some additional considerations apply:
- The European Society of Cardiology consensus statement indicates that for class 1-2 obesity (BMI 30-40), no change in the standard prophylactic dose is needed 1.
- For class 3 obesity (BMI >40), some experts suggest increasing the daily dose or frequency (twice daily dosing) for high-risk patients 1.
With a weight of 114kg, the patient likely falls into class 2 obesity (depending on height), so the standard 40mg once daily dose would still be appropriate.
Monitoring Considerations
- Anti-Xa monitoring is not routinely required for prophylactic dosing but may be considered in patients with severe obesity (BMI >40) 1, 2.
- For patients with renal impairment (CrCl <30 mL/min), a dose reduction to 30mg once daily would be recommended 1.
Duration of Prophylaxis
- For hospitalized medical patients, prophylaxis should continue for the length of hospital stay or until the patient is fully ambulatory 1.
- For surgical patients, prophylaxis should continue for at least 7-10 days, with extended prophylaxis for up to 4 weeks considered for high-risk patients 1.
Alternative Prophylactic Options
If enoxaparin is contraindicated or unavailable, alternative options include:
- Unfractionated heparin 5,000 units subcutaneously every 8 hours 1
- Dalteparin 5,000 units subcutaneously once daily 1
- Fondaparinux 2.5mg subcutaneously once daily 1
Important Caveats
- Ensure there are no contraindications to pharmacologic prophylaxis such as active bleeding, severe thrombocytopenia, or recent neurosurgery.
- For patients with high bleeding risk, mechanical prophylaxis with intermittent pneumatic compression devices should be considered.
- The prophylactic dose (40mg daily) should not be confused with the therapeutic dose used for treatment of established DVT/PE (1mg/kg twice daily or 1.5mg/kg once daily).
Remember that this recommendation is specifically for DVT prophylaxis. If the patient has an established DVT requiring treatment rather than prophylaxis, a different weight-based dosing regimen would be appropriate.