Lovenox (Enoxaparin) Bridging Protocol for Patients with Impaired Renal Function
For patients with impaired renal function requiring enoxaparin bridging, the dose should be reduced to 1 mg/kg subcutaneously once daily when creatinine clearance is less than 30 mL/min. 1
Dosing Recommendations Based on Renal Function
Normal Renal Function (CrCl >80 mL/min)
- Standard therapeutic dosing: 1 mg/kg subcutaneously every 12 hours 1
- Initial IV loading dose of 30 mg may be used in selected patients 1
Moderate Renal Impairment (CrCl 30-60 mL/min)
- Consider dose reduction to 0.8 mg/kg subcutaneously every 12 hours 2
- Alternative approach: 0.75 mg/kg subcutaneously every 12 hours 3
- Higher risk of bleeding events compared to normal renal function (22% vs 5.7%) if standard doses are used 4
Severe Renal Impairment (CrCl <30 mL/min)
- Reduce dose to 1 mg/kg subcutaneously once daily 1
- Consider alternative management with unfractionated heparin (UFH) 1
- For prophylactic dosing: 30 mg subcutaneously once daily 1
- For very high-risk patients with severe renal failure requiring prophylaxis only: 20 mg subcutaneously once daily may be considered 5
Monitoring Recommendations
Anti-Xa Monitoring
- For patients with severe renal impairment (CrCl <30 mL/min): 3
- Obtain anti-Xa level 4 hours after the third dose
- Target therapeutic range: 0.5-1.0 IU/mL
- If adjustment needed: New dose = [(Current dose) × (Goal anti-Xa level)]/(Current anti-Xa level)
Special Considerations
- Patients with cancer and severe renal impairment (CrCl <30 mL/min) on dalteparin should have peak anti-Xa levels monitored to achieve target range of 0.5-1.5 IU/mL 1
- Anti-Xa levels should be measured 4-6 hours after dosing, after patient has received 3-4 doses 1
Duration of Bridging
- For patients with STEMI/NSTEMI: minimum of 48 hours, preferably for the duration of hospitalization (up to 8 days) or until revascularization if performed 1
- For patients transitioning to oral anticoagulants: continue until therapeutic INR is achieved if transitioning to warfarin
Important Precautions
- Do not switch between enoxaparin and unfractionated heparin due to increased risk of bleeding 1
- Critically ill patients may have lower anti-Xa levels with standard subcutaneous dosing, requiring closer monitoring 6
- Elderly patients (≥75 years) have higher bleeding risk and may require additional dose adjustments 1
- For patients undergoing procedures, timing of last dose is critical to minimize bleeding risk while maintaining anticoagulation
Alternative Anticoagulants for Severe Renal Impairment
- Unfractionated heparin: Weight-based IV bolus of 60 U/kg (maximum 4000 U) followed by infusion of 12 U/kg/h (maximum 1000 U/h), adjusted to maintain aPTT at 1.5-2.0 times control 1
- Bivalirudin: For patients with HIT requiring continued anticoagulation; adjust dose for renal impairment (CrCl <30 mL/min: 1 mg/kg/h) 1
- Fondaparinux: Contraindicated in patients with CrCl <30 mL/min 1