What are the doses of enoxaparin (low molecular weight heparin) and dalteparin (low molecular weight heparin) for anticoagulation in cancer patients?

Dosing of Enoxaparin and Dalteparin for Anticoagulation in Cancer

For cancer patients requiring anticoagulation, dalteparin should be dosed at 200 units/kg SC daily for 30 days, then reduced to 150 units/kg once daily for extended treatment, while enoxaparin should be dosed at 1 mg/kg SC every 12 hours (or 0.8 mg/kg SC every 12 hours for patients with BMI ≥40 kg/m²). 1

Recommended Dosing Regimens

Dalteparin (FDA-approved for cancer-associated VTE)

• Initial treatment: 200 units/kg SC daily for 30 days 1
• Extended treatment: Reduce to 150 units/kg SC daily after first month 1
• Category 1 recommendation (highest level of evidence) for treatment of DVT/PE in cancer patients 1
• Only LMWH specifically FDA-approved for extended treatment of symptomatic VTE in cancer patients 1

Enoxaparin

• Standard dosing: 1 mg/kg SC every 12 hours 1
• For patients with BMI ≥40 kg/m²: 0.8 mg/kg SC every 12 hours 1
• Alternative dosing: May consider 1.5 mg/kg SC once daily, though twice-daily dosing may be more efficacious 2, 3
• Can consider decreasing intensity to 1.5 mg/kg daily after first month 1

Special Populations and Dose Adjustments

Renal Impairment

• For enoxaparin in severe renal insufficiency (CrCl <30 mL/min): Dose reduction required due to 2-3 fold increased bleeding risk 1
• For dalteparin in renal impairment: May be sufficiently cleared but monitoring of peak anti-Xa levels is recommended in patients with CrCl <30 mL/min 1

Thrombocytopenia

• Platelet count >50,000/mcL: Full dose enoxaparin 4
• Platelet count 25,000-50,000/mcL: Half-dose enoxaparin 4
• Platelet count <25,000/mcL: Hold anticoagulation 4

Comparative Efficacy and Safety

• Dalteparin has been found to be more effective than warfarin for preventing recurrent VTE (8.0% vs 15.8%; HR, 0.48; P=0.002) without increasing bleeding risk 1
• Enoxaparin has demonstrated efficacy compared to warfarin with lower rates of combined outcomes including major bleeding or recurrent VTE (10.5% vs 21.1%) 1
• A small study comparing once daily vs twice daily enoxaparin in cancer patients with PE found potentially higher rates of recurrent PE in the once-daily group (4 vs 2 patients) 3

Duration of Therapy

• Extended anticoagulation therapy with LMWHs is recommended for cancer patients with VTE 1
• The European Society for Medical Oncology (ESMO) recommends using 75%-80% of the initial dose of LMWH for extended anticoagulation therapy 1
• After the initial treatment period, dalteparin dosing should be lowered from 200 units/kg daily to 150 units/kg daily 1

Clinical Pearls and Pitfalls

• Despite both being LMWHs, dalteparin has the highest quality evidence supporting its use in cancer patients and is the only LMWH FDA-approved specifically for cancer-associated VTE 1
• Long-term treatment with enoxaparin dosing of 1.0 mg/kg SC every 12 hours has not been extensively tested specifically in cancer patients 1
• Institutions should develop LMWH dosing algorithms tailored for special populations (renal insufficiency, obesity, low weight, elderly) 1
• Regular monitoring of CBC, renal function, and signs of bleeding is essential during treatment 1