From the Guidelines
Lovenox (enoxaparin) dosing should be reduced in chronic kidney disease (CKD) patients due to decreased renal clearance, with a recommended dose of 30 mg of subcutaneous enoxaparin daily for VTE prophylaxis and 1 mg/kg subcutaneously every 24 hours for VTE treatment for patients with creatinine clearance (CrCl) less than 30 mL/min, as supported by the manufacturer's recommendations 1. For patients with CKD, it is essential to consider the renal clearance of enoxaparin, as impaired renal function can lead to drug accumulation and increased bleeding risk.
- The renal clearance of enoxaparin is reduced by 31% and 44% in patients with moderate (30–60 mL/min) and severe renal impairment (<30 mL/min), respectively 1.
- Some evidence supports downward dose adjustments of enoxaparin in the management of patients with CrCl of 30 to 60 mL/min 1.
- Monitoring of anti-Factor Xa levels is recommended when using therapeutic doses in CKD patients, aiming for 0.5-1.0 IU/mL for twice-daily dosing or 1.0-2.0 IU/mL for once-daily dosing, measured 4 hours after administration 1.
- Patients on hemodialysis should receive enoxaparin after dialysis sessions to prevent removal of the medication.
- Alternative anticoagulants like unfractionated heparin may be considered in patients with severe renal impairment (CrCl <15 mL/min) requiring full anticoagulation, as it's not dependent on renal clearance. The dosing recommendations for enoxaparin in CKD patients are based on the results of clinical studies and manufacturer's guidelines, which emphasize the importance of dose adjustments to minimize the risk of bleeding complications 1.
From the Research
Dosing of Lovenox (Enoxaparin) in Patients with Chronic Kidney Disease (CKD)
- The dosing of enoxaparin in patients with CKD should be adjusted according to creatinine clearance or glomerular filtration rate 2
- For patients with a creatinine clearance of less than 30 mL/min, enoxaparin 1 mg/kg/day can be safely administered once a day 3
- However, other studies suggest that enoxaparin accumulates in patients with a creatinine clearance of 30 ml/minute or less, and dosage adjustments have been attempted 4
- A population pharmacokinetic analysis recommends a dosing strategy for patients with renal impairment, with a first unadjusted dose of 1 mg/kg followed by a regimen of 0.8 mg/kg/12h in patients with moderate renal impairment or 0.66 mg/kg/12h in patients with severe renal impairment 5
- Another study suggests that enoxaparin should be adjusted to 50-65% of the original dose for patients with a creatinine clearance of <30 ml/min and 75-85% of the original dose for patients with a creatinine clearance of 30-60 ml/min 6
Monitoring of Anti-Xa Levels
- Peak anti-Xa monitoring is not supported by data as a means of adjusting LMWH dose in patients with renal insufficiency 6
- Trough concentration anti-Xa monitoring is preferred over peak monitoring, aiming at a maximum concentration of 0.4 IU/mL for once-daily dosed tinzaparin and 0.5 IU/mL for twice-daily dosed enoxaparin and nadroparin 6
Special Considerations
- Obese patients weighing 90-150 kg should receive dosages based on total body weight 4
- Unfractionated heparin is recommended in patients weighing more than 150 kg; however, if LMWH is used, anti-Xa levels should be monitored 4
- Bridging with enoxaparin should be limited to patients with a creatinine clearance greater than 30 ml/minute 4