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 dalteparin being preferred for cancer patients due to its specific FDA approval for extended treatment in this population. 1

General Selection Criteria

The choice between enoxaparin and dalteparin should be based on:

1. Patient-specific factors:

   • Renal function
   • Body weight
   • Cancer status
   • Inpatient/outpatient status
   • Bleeding risk

2. Specific indications:

Enoxaparin (Clexane) Preferred For:

• Standard DVT/PE prophylaxis in most surgical and medical patients
• Twice-daily dosing regimens when needed
• Patients with renal function that requires dose adjustment (has established dosing protocols)

Dalteparin (Fragmin) Preferred For:

• Cancer patients requiring extended treatment (6 months) of VTE 1, 2
• Patients with unstable angina or non-Q-wave myocardial infarction 2
• Once-daily dosing preference in appropriate patients

Dosing Guidelines

Enoxaparin Dosing:

• Prophylactic dosing: 40 mg subcutaneously once daily 1
• Treatment dosing: 1 mg/kg twice daily or 1.5 mg/kg once daily 1
• Renal impairment (CrCl <30 mL/min): 30 mg once daily for prophylaxis; 1 mg/kg once daily for treatment 1
• Obesity (BMI >40): Consider 40 mg twice daily or 0.5 mg/kg twice daily for prophylaxis 1

Dalteparin Dosing:

• Cancer patients with VTE: 200 IU/kg daily for first month, then 150 IU/kg daily for extended treatment (up to 6 months) 1, 2
• Unstable angina/non-Q-wave MI: 120 IU/kg (max 10,000 units) every 12 hours with concurrent aspirin 2
• DVT prophylaxis post-hip replacement: Various options available based on timing relative to surgery 2

Special Populations

Cancer Patients

• Dalteparin is specifically FDA-approved for extended treatment (6 months) of symptomatic VTE in cancer patients 1, 2, 3
• The CLOT study demonstrated efficacy of dalteparin in reducing VTE recurrence in cancer patients 1

Renal Impairment

• For severe renal insufficiency (CrCl <30 mL/min):
  • Enoxaparin: 30 mg once daily for prophylaxis; 1 mg/kg once daily for treatment 1
  • Consider monitoring anti-Xa levels in these patients 1

Obesity

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

Pregnant Women

• May require dose adjustments based on anti-Xa levels, though routine monitoring is not recommended by the American Society of Hematology 1

Safety Considerations

• Both medications carry risk of spinal/epidural hematomas when used with neuraxial anesthesia 2
• Both should be avoided in patients with history of heparin-induced thrombocytopenia (HIT) 1
• Platelet monitoring is recommended during treatment 1
• Comparative studies show similar safety profiles between enoxaparin and dalteparin 4

Efficacy Comparison

• Head-to-head trials show no significant differences in efficacy between tinzaparin and dalteparin for outpatient treatment of DVT and PE 4
• Enoxaparin has demonstrated comparable effects for reduction of VTE recurrence and all-cause mortality versus other approved LMWHs 3
• Recurrent VTE rates are reported as 4.1% for enoxaparin and 5.0% for dalteparin 1

Common Pitfalls to Avoid

1. Failing to adjust doses for renal impairment
2. Using standard fixed doses in morbidly obese patients without consideration of weight-based dosing
3. Not considering cancer status when selecting between agents
4. Overlooking neuraxial anesthesia risk when scheduling patients for spinal procedures
5. Inadequate monitoring in high-risk populations (severe renal impairment, morbid obesity)

When treating cancer patients with VTE, remember that dalteparin has the strongest evidence base and specific FDA approval for extended treatment in this population, making it the preferred choice.