What is the recommended dose of Lovenox (enoxaparin) for acute ischemic stroke?

Lovenox Dosing for Acute Ischemic Stroke

Lovenox (enoxaparin) is NOT recommended for treating acute ischemic stroke to reduce morbidity, mortality, or prevent early stroke recurrence, but IS recommended at 40 mg subcutaneously once daily specifically for DVT prophylaxis in immobilized stroke patients. 1

Critical Distinction: Treatment vs. Prophylaxis

NOT Recommended for Stroke Treatment

• High-dose LMWH (including enoxaparin) has NOT been associated with benefit in reducing morbidity, mortality, or early recurrent stroke and is therefore not recommended for these therapeutic goals 1
• Multiple trials have shown that the potential benefits of anticoagulation for stroke treatment are negated by concomitant increases in hemorrhagic complications 1
• No specific stroke subgroup (cardioembolic, large vessel atherosclerotic, vertebrobasilar, or "progressing" stroke) has been shown to benefit from therapeutic-dose enoxaparin 1

RECOMMENDED for VTE Prophylaxis Only

For immobilized acute ischemic stroke patients, enoxaparin 40 mg subcutaneously once daily is the preferred regimen for DVT prophylaxis 1, 2

Evidence Supporting This Dose:

• The PREVAIL trial demonstrated that enoxaparin 40 mg once daily was superior to unfractionated heparin 5000 IU twice daily, reducing VTE risk by 43% (10% vs 18%, p=0.0001) 2
• This benefit was consistent across stroke severity (NIHSS ≥14 and <14) 2
• The risk of symptomatic intracranial hemorrhage was similar between groups (1% vs 1%), though major extracranial bleeding was slightly higher with enoxaparin (1% vs 0%) 2

Duration of Prophylaxis:

• Standard duration is 10 days (range 6-14 days) for hospitalized patients 2, 3
• Extended prophylaxis for 4-5 weeks may provide additional VTE reduction with minimal increase in bleeding risk, though this is not yet standard practice 4

Acute Stroke Management Algorithm

Within 48 Hours of Stroke Onset:

1. Immediate antiplatelet therapy (NOT anticoagulation):

   • Aspirin 160-325 mg loading dose after hemorrhage excluded 1, 5
   • Continue aspirin 81-325 mg daily for secondary prevention 1, 5

2. VTE prophylaxis for immobilized patients:

   • Enoxaparin 40 mg subcutaneously once daily 1, 2
   • Alternative: Intermittent pneumatic compression devices 1
   • Avoid elastic compression stockings (not effective) 1

Common Pitfalls to Avoid

• Do not use therapeutic-dose enoxaparin (such as 1 mg/kg twice daily used in ACS) for stroke treatment—this increases bleeding without proven benefit 1
• Do not confuse VTE prophylaxis dosing with treatment dosing—the 40 mg once daily dose is specifically for prophylaxis only 2
• Do not delay aspirin therapy in favor of anticoagulation—aspirin should be started within 48 hours unless contraindicated 1, 6
• The catheter should be removed as soon as medically stable to reduce infection risk 1

Special Considerations

• Patients with atrial fibrillation and stroke require oral anticoagulation (not enoxaparin) for long-term secondary prevention 1, 6
• For patients requiring both thrombolysis and VTE prophylaxis, delay prophylactic anticoagulation until after the acute thrombolytic period 1