Should Lovenox (enoxaparin) be stopped after midnight for a procedure scheduled the next day?

Perioperative Management of Enoxaparin (Lovenox)

Enoxaparin (Lovenox) should be discontinued at least 24 hours before a procedure to minimize bleeding risk. 1

Timing of Discontinuation Based on Procedure Risk

Low Bleeding Risk Procedures

• For procedures with low bleeding risk, the last dose of enoxaparin should be taken 24 hours before the procedure 2
• If enoxaparin is administered twice daily, the last dose should be on the morning of the day before the procedure 2
• If enoxaparin is administered once daily in the morning, the last dose should be on the morning of the day before the procedure 2
• If enoxaparin is administered once daily in the evening, the last dose should be two days before the procedure 2

High Bleeding Risk Procedures

• For procedures with high bleeding risk, enoxaparin should be discontinued at least 24 hours before the procedure 1
• In patients with normal renal function, the last dose of enoxaparin should be administered approximately 24 hours before surgery 2
• For patients with impaired renal function (CrCl 15-30 mL/min), consider extending this window to at least 36 hours before the procedure 2

Special Considerations

Renal Function

• Patients with impaired renal function require longer interruption periods due to prolonged drug elimination 2:
  • CrCl 50-79 mL/min: ≥24 hours for low-risk procedures, ≥48 hours for high-risk procedures
  • CrCl 30-49 mL/min: ≥24 hours for low-risk procedures, ≥48 hours for high-risk procedures
  • CrCl 15-29 mL/min: ≥36 hours for low-risk procedures, ≥48 hours for high-risk procedures 2

Neuraxial Procedures

• For procedures involving epidural or spinal anesthesia/analgesia, enoxaparin should be stopped at least 12 hours before the procedure for prophylactic doses (30-40 mg once daily) 1
• For therapeutic doses (0.75-1 mg/kg twice daily or 1.5 mg/kg once daily), enoxaparin should be stopped at least 24 hours before neuraxial procedures 1

Resumption After Procedure

• For low bleeding risk procedures, enoxaparin can be resumed at least 6 hours after the procedure 2
• For high bleeding risk procedures, resumption should be delayed for 24-48 hours and dependent on achieving adequate surgical hemostasis 2
• If there is ongoing bleeding risk, consider using mechanical thromboprophylaxis until it is safe to resume pharmacological prophylaxis 2

Common Pitfalls to Avoid

• Bridging with unfractionated heparin is not recommended when interrupting enoxaparin therapy, as mixing two anticoagulants has been associated with increased bleeding risk 2
• Avoid checking INR for monitoring enoxaparin effect as it is not a reliable indicator of anticoagulant activity 2
• Do not restart enoxaparin at full therapeutic dose immediately after high bleeding risk procedures; consider using prophylactic doses initially 2
• Failure to adjust discontinuation timing based on renal function can lead to excessive anticoagulation during the procedure 2, 1

Monitoring Recommendations

• Consider checking hemoglobin levels before the procedure 3
• Monitor for signs of bleeding after resuming enoxaparin 1
• An unexplained fall in hematocrit or blood pressure should prompt investigation for a bleeding site 1

By following these guidelines, the risk of perioperative bleeding can be minimized while maintaining appropriate thromboprophylaxis for patients requiring procedures.