What is the dosing regimen for Lovenox (enoxaparin) for the prevention and treatment of deep vein thrombosis (DVT) and pulmonary embolism?

Lovenox (Enoxaparin) Dosing Regimens for DVT and PE

For prevention and treatment of DVT/PE, enoxaparin dosing is 40 mg once daily for prophylaxis and 1 mg/kg twice daily for treatment, with specific adjustments needed for special populations. 1, 2

Prophylactic Dosing

Standard Prophylaxis

• Standard dose: 40 mg subcutaneously once daily 1, 2
• Duration:
  • Medical patients: Until fully ambulatory or hospital discharge 1
  • Surgical patients: At least 7-10 days; consider extending to 4 weeks for high-risk patients 1
  • Outpatients with cancer: Up to 6 months 1

Special Populations for Prophylaxis

• High-risk surgical patients: 30 mg subcutaneously twice daily 2
• Severe renal impairment (CrCl <30 mL/min): 30 mg subcutaneously once daily 2
• Obesity (BMI >40 kg/m²): 40 mg twice daily or 0.5 mg/kg twice daily 2

Treatment Dosing for Established DVT/PE

Standard Treatment

• Initial treatment: 1 mg/kg subcutaneously every 12 hours 1
  • Alternative regimen: 1.5 mg/kg subcutaneously once daily 1
• Duration: Minimum 5-7 days and until INR is therapeutic if transitioning to warfarin 1, 2
• Long-term treatment:
  • For cancer patients: Continue at 1 mg/kg every 12 hours or consider decreasing intensity to 1.5 mg/kg daily after first month 1
  • Standard duration: 3-6 months for provoked VTE; at least 6 months for unprovoked VTE 3

Special Populations for Treatment

• Obesity (BMI ≥40 kg/m²): 0.8 mg/kg subcutaneously every 12 hours 1
• Severe renal impairment (CrCl <30 mL/min): Dose reduction required or consider unfractionated heparin 2
• Cancer patients: 1 mg/kg every 12 hours; can consider decreasing to 1.5 mg/kg daily after first month 1

Monitoring Requirements

• Standard patients: Routine monitoring of anti-Xa levels not required 2
• Special populations requiring monitoring:
  • Severe renal impairment
  • Extreme obesity (BMI >40 kg/m²)
  • Pregnancy with class III obesity
  • Target anti-Xa level: 0.5-1.5 IU/mL (measured 4-6 hours after injection) 2
• Platelet monitoring: Recommended during treatment due to risk of heparin-induced thrombocytopenia 1

Transitioning to Oral Anticoagulants

• To warfarin: Overlap enoxaparin with warfarin for 5-7 days until INR is 2.0-3.0 for two consecutive days 2
• To direct oral anticoagulants: Follow specific protocols for each agent; concurrent administration not recommended when transitioning to edoxaban or dabigatran 1

Clinical Pearls

• Enoxaparin has better predictability and reduced monitoring requirements compared to unfractionated heparin 2
• For cancer patients, LMWH is preferred over warfarin for long-term treatment 1
• Bioaccumulation risk is higher in patients with renal insufficiency 2
• Avoid in patients with severe hepatic disease or hepatic coagulopathy 2
• Consider inferior vena cava filters only when anticoagulation is contraindicated or when PE recurs despite optimal anticoagulation 1

This dosing guidance prioritizes mortality and morbidity reduction while maintaining safety across different patient populations.