Recommended Dosing of Lovenox (Enoxaparin) for Treatment of Venous Thromboembolism
For the treatment of venous thromboembolism (VTE), the standard recommended dose of enoxaparin is 1 mg/kg subcutaneously every 12 hours or 1.5 mg/kg subcutaneously once daily. 1, 2
Standard Dosing Regimens
- Twice-daily regimen: 1 mg/kg subcutaneously every 12 hours
- Once-daily regimen: 1.5 mg/kg subcutaneously once daily
Both dosing regimens are FDA-approved and have demonstrated equivalent efficacy and safety in clinical trials 3. However, some evidence suggests that twice-daily dosing may be more efficacious than once-daily dosing in certain populations, particularly cancer patients 4.
Special Population Considerations
Renal Impairment
- Severe renal insufficiency (CrCl <30 mL/min): Reduce to 1 mg/kg subcutaneously once daily 1, 2
- Moderate renal impairment (CrCl 30-50 mL/min): Consider dose reduction as renal clearance of enoxaparin can be reduced by 31% 1
- Monitor anti-Xa levels in patients with severe renal impairment
Obesity
- For patients with BMI >40 kg/m²: Consider anti-Xa monitoring with standard dosing or use 0.8 mg/kg every 12 hours 2
- Obese patients may require higher total doses but potentially lower weight-based doses
- No established upper limit for total daily dose, but caution is advised with extremely high doses
Underweight Patients
- Patients <50 kg: Use standard weight-based dosing (1 mg/kg twice daily or 1.5 mg/kg once daily) 2, 5
- Monitor closely for bleeding complications
Elderly Patients
- Use caution in elderly patients (≥70 years)
- Consider renal function when determining appropriate dosing
Extended Treatment
For extended treatment of VTE (beyond initial period):
- Consider reducing the dose to 75-80% of the initial dose after the first month 1, 2
- For example, if using dalteparin, reduce from 200 IU/kg daily to 150 IU/kg daily after 1 month 1
Monitoring
- Routine monitoring of anti-Xa levels is not required for most patients
- Consider monitoring anti-Xa levels in:
- Patients with severe renal impairment
- Extremely obese patients
- Patients with low body weight
- Target anti-Xa level: 0.5-1.5 IU/mL (measured 4-6 hours after injection) 2
Important Considerations
- When transitioning to warfarin, overlap therapy is typically required for 5-7 days and until INR is therapeutic (2.0-3.0) for 2 consecutive days 1
- Enoxaparin has a higher risk of bioaccumulation in renal impairment compared to dalteparin 2
- For cancer-associated thrombosis, dalteparin has the highest quality evidence and is FDA-approved specifically for this indication 2
Cautions
- Avoid in patients with history of heparin-induced thrombocytopenia (HIT)
- Use with caution in patients with severe hepatic disease or hepatic coagulopathy
- Monitor for bleeding complications, especially in high-risk patients