When should we use Clexane (enoxaparin) and Fragmin (dalteparin) for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) prevention?

When to Use Clexane (Enoxaparin) and Fragmin (Dalteparin)

Both Clexane (enoxaparin) and Fragmin (dalteparin) are effective for DVT and PE prevention and treatment, with the choice between them primarily based on specific patient factors including renal function, body weight, and cancer status, with dalteparin being preferred for cancer patients due to its specific FDA approval for extended treatment in this population. 1

General Indications for Both Medications

Both enoxaparin and dalteparin are low-molecular-weight heparins (LMWHs) indicated for:

• Prophylaxis of DVT in high-risk surgical patients (orthopedic, abdominal surgery)
• Prophylaxis in medical patients with restricted mobility
• Treatment of acute DVT with or without PE
• Prevention of ischemic complications in unstable angina and non-Q-wave MI

Specific Indications and Considerations

Enoxaparin (Clexane) is preferred for:

• Patients requiring renal dose adjustments (specific dosing guidelines available)
• FDA approved for both prophylaxis and immediate treatment of VTE 1
• Standard dosing: 1 mg/kg twice daily or 1.5 mg/kg once daily for treatment 1
• Prophylactic dosing: 40 mg once daily (standard) or 30 mg once daily (renal impairment) 2

Dalteparin (Fragmin) is preferred for:

• Cancer patients requiring extended treatment (6 months) of symptomatic VTE 1
• FDA approved for VTE prophylaxis and extended treatment in cancer patients 3
• Treatment dosing: 200 IU/kg daily (first month), then 150 IU/kg daily for extended treatment 1
• Prophylactic dosing: 5000 IU daily 3

Special Populations

Renal Impairment

• For severe renal insufficiency (CrCl <30 mL/min):
  • Enoxaparin: Use 30 mg once daily for prophylaxis and 1 mg/kg once daily for treatment 1, 2
  • Dalteparin: Use with caution; monitoring of anti-Xa levels recommended if CrCl <30 mL/min 1

Cancer Patients

• Dalteparin is specifically FDA-approved for extended treatment (6 months) of VTE in cancer patients 1, 3
• The CLOT study demonstrated efficacy of dalteparin in reducing VTE recurrence in cancer patients 1
• Recent evidence suggests enoxaparin has a similar benefit-risk profile to dalteparin in cancer patients 4

Obesity

• For morbidly obese patients (BMI >40 kg/m²):
  • Consider anti-Xa monitoring for both medications 1, 2
  • Fixed-dose regimens may be inadequate; weight-based dosing preferred 1

Elderly Patients

• Use caution with tinzaparin in patients >70 years with renal insufficiency 1
• Both enoxaparin and dalteparin can be used in elderly patients with appropriate dose adjustments 2

Comparative Efficacy and Safety

Direct comparative studies between enoxaparin and dalteparin are limited, but available evidence suggests:

• Similar efficacy in preventing recurrent VTE 5
• Comparable safety profiles regarding bleeding risk 5
• Table 15 from the American Heart Association shows recurrent VTE rates of 4.1% for enoxaparin and 5.0% for dalteparin 1

Practical Considerations

• Dalteparin is often administered once daily (200 IU/kg), which may improve adherence 3
• Enoxaparin can be administered once daily (1.5 mg/kg) or twice daily (1 mg/kg) 1
• For outpatient treatment, both medications have demonstrated safety and efficacy 5

Important Caveats

• Avoid both medications in patients with history of heparin-induced thrombocytopenia (HIT) 1
• Monitor platelet counts during treatment due to risk of HIT 2
• Neither should be used with neuraxial anesthesia/spinal puncture without appropriate timing considerations 3
• For patients undergoing procedures, appropriate interruption times must be followed 1

When selecting between these medications, consider the patient's specific condition (cancer vs. non-cancer), renal function, body weight, and the need for extended therapy to guide your decision.