What is the recommended dosing of Lovenox (enoxaparin) leading up to Percutaneous Coronary Intervention (PCI)?

Enoxaparin Dosing for Percutaneous Coronary Intervention (PCI)

For patients undergoing PCI, enoxaparin should be administered as a 0.5-0.75 mg/kg IV bolus for anticoagulant-naïve patients, with a 0.3 mg/kg IV bolus for those who received subcutaneous enoxaparin 8-12 hours prior to the procedure. 1

Dosing Algorithm Based on Prior Enoxaparin Use

For Patients Not Previously on Enoxaparin:

• Initial dose: 0.5-0.75 mg/kg IV bolus 1
  • The 0.5 mg/kg dose is preferred as it provides adequate anticoagulation while reducing bleeding risk compared to higher doses 1, 2
  • This single bolus provides sufficient anticoagulation for most PCI procedures 1

For Patients Already on Subcutaneous Enoxaparin:

• If last SC dose was <8 hours before PCI: No additional enoxaparin needed 3, 1
• If last SC dose was 8-12 hours before PCI: Administer 0.3 mg/kg IV bolus 3, 1
• If last SC dose was >12 hours before PCI: Use full-dose anticoagulation (0.5-0.75 mg/kg IV) 1

Important Clinical Considerations

Advantages of Enoxaparin for PCI:

• More predictable anticoagulation levels compared to unfractionated heparin 2
• Target anticoagulation levels are reached in significantly more patients with enoxaparin (79-92%) compared to unfractionated heparin (20%) 2
• Does not require routine ACT monitoring during PCI 1, 4

Safety Profile:

• The 0.5 mg/kg dose is associated with reduced rates of non-CABG-related bleeding compared to unfractionated heparin (5.9% vs 8.5%) 2
• Significant reduction in major bleeding events with both 0.5 mg/kg and 0.75 mg/kg doses compared to unfractionated heparin 2
• Lower risk of bleeding (OR=0.47) and fewer significant hemoglobin decreases (OR=0.45) compared to unfractionated heparin 5

Post-PCI Management:

• Anticoagulation should be discontinued after uncomplicated PCI unless there is a compelling reason to continue 1
• Sheath removal can be performed 4 hours after the last IV dose or 6-8 hours after the last subcutaneous dose 1

Special Considerations

Monitoring:

• Unlike unfractionated heparin, ACT monitoring is not useful for assessing anticoagulation with enoxaparin 4
• Anti-Xa levels >0.5 IU/ml are achieved in 97.5% of patients with the 0.5 mg/kg IV dose 6

Patient Factors:

• The 0.5 mg/kg dose appears effective regardless of age, weight, renal function, or concomitant use of glycoprotein IIb/IIIa inhibitors 6
• For patients receiving glycoprotein IIb/IIIa inhibitors, the same dosing strategy can be applied 6, 7

Caution:

• Do not administer unfractionated heparin to patients already on therapeutic subcutaneous enoxaparin within the past 12 hours due to increased bleeding risk 1