What is the treatment dose for Clexane (enoxaparin)?

Clexane (Enoxaparin) Treatment Dosing

For therapeutic anticoagulation in venous thromboembolism (VTE), the standard treatment dose of enoxaparin is 1 mg/kg subcutaneously every 12 hours or 1.5 mg/kg subcutaneously once daily. 1, 2

Standard Treatment Regimens

Twice-Daily Dosing (Preferred)

• 1 mg/kg subcutaneously every 12 hours is the most established therapeutic regimen for DVT/PE treatment 1, 2
• This dosing has been proven equivalent to unfractionated heparin for both efficacy (symptomatic VTE recurrence) and safety (major hemorrhage) in large prospective trials 1
• Treatment should continue for at least 5 days and overlap with warfarin until INR >2.0 for 2 consecutive days 3

Once-Daily Dosing (Alternative)

• 1.5 mg/kg subcutaneously once daily is an FDA-approved alternative regimen 1, 2
• This dosing offers improved patient compliance and reduced healthcare worker exposure 3
• Target peak anti-Xa level is 1.0-1.5 IU/mL (measured 4 hours post-dose), compared to 0.6-1.0 IU/mL for twice-daily dosing 3
• Important caveat: Some evidence suggests once-daily dosing may carry higher risk of recurrent PE and major bleeding in cancer patients (15% vs 6% bleeding rate) 4

Critical Dose Adjustments

Severe Renal Impairment (CrCl <30 mL/min)

• Reduce dose to 1 mg/kg subcutaneously once daily (50% total daily dose reduction) 1, 5
• This adjustment is mandatory because enoxaparin clearance is reduced by 44% in severe renal failure, increasing bleeding risk nearly 4-fold (8.3% vs 2.4%) without dose adjustment 5
• Consider switching to unfractionated heparin as the preferred alternative, which requires no renal dose adjustment 5
• Monitor anti-Xa levels with target range 0.5-1.5 IU/mL, measured 4 hours after the 3rd or 4th dose 1, 5

Obesity (BMI ≥40 kg/m²)

• Use 0.8 mg/kg subcutaneously every 12 hours (reduced from standard 1 mg/kg) 1, 3
• A randomized trial showed 89.3% of patients on reduced-dose (0.8 mg/kg) reached goal anti-Xa levels versus 76.9% on standard dosing 1

Cancer Patients

• Use standard therapeutic dosing initially: 1 mg/kg every 12 hours or 1.5 mg/kg once daily 1, 2
• After 1 month, reduce to 75-80% of initial dose for extended anticoagulation 1
• Continue for minimum 6 months, or indefinitely while cancer remains active 3
• The CLOT study used dalteparin 200 units/kg daily reduced to 150 units/kg after 1 month, establishing this dose-reduction principle 1

Duration of Treatment

• Minimum 5-10 days for initial treatment of acute DVT/PE 1, 3
• Provoked VTE: Treat for exactly 3 months if due to reversible risk factor (surgery, trauma) 3
• Unprovoked VTE: Minimum 3-6 months initially, then consider indefinite therapy 3
• Cancer-associated VTE: Minimum 6 months, indefinitely while cancer active 1, 3

Monitoring Requirements

Routine Monitoring

• Platelet count every 2-3 days from day 4 to day 14 to screen for heparin-induced thrombocytopenia 1, 5
• Hemoglobin, hematocrit every 2-3 days for first 14 days, then every 2 weeks 3
• Baseline CBC, renal and hepatic function, aPTT, PT/INR before initiation 3

Anti-Xa Level Monitoring (When Indicated)

• Required in: Severe renal impairment (CrCl <30 mL/min), pregnancy with therapeutic doses, morbid obesity, patients <50 kg or >150 kg 1, 2, 3
• Measure 4 hours after administration, after 3-4 doses have been given 3, 5
• Target range: 0.6-1.0 IU/mL for twice-daily dosing; 1.0-1.5 IU/mL for once-daily dosing 3

Common Pitfalls and Contraindications

Absolute Contraindications

• Active major bleeding 1
• Severe thrombocytopenia (platelet count <50,000/μL) 1

Critical Timing Considerations

• Neuraxial anesthesia: Avoid enoxaparin within 10-12 hours before spinal/epidural procedures to prevent spinal hematoma 2, 3
• For prophylactic doses (40 mg once daily), may restart 4 hours after catheter removal but not before 12 hours after the block 2, 3
• For therapeutic doses, wait 24 hours after the block before restarting 2

Drug Interactions

• Never switch between enoxaparin and unfractionated heparin during the same hospitalization due to increased bleeding risk 3, 5
• Use cautiously with antiplatelet agents (aspirin, clopidogrel) due to additive bleeding risk 3

Special Populations to Avoid

• Dialysis patients: Strongly consider unfractionated heparin instead; if enoxaparin used, administer 6-8 hours after hemodialysis completion 5
• Moderate-to-severe liver disease with coagulopathy: Avoid enoxaparin (elevated transaminases alone without coagulopathy are acceptable) 5