Should Lovenox (enoxaparin) be held in a patient scheduled for hip surgery?

From the Guidelines

The last dose of lovenox (enoxaparin) should be held 12 hours before hip surgery for patients undergoing orthopedic surgery, as recommended in the guidelines for VTE prophylaxis strategies 1. When considering the management of anticoagulation in patients undergoing elective surgeries, such as hip surgery, it's crucial to balance the risk of bleeding with the risk of venous thromboembolism (VTE).

• The timing of holding lovenox is critical to minimize bleeding risks while maintaining thromboprophylaxis.
• For patients scheduled for hip surgery, the recommended dose of enoxaparin is 30 mg twice daily, started 12 hours before or after surgery, and continued for 10-14 days, with consideration of extension up to 35 days 1.
• After surgery, lovenox can typically be restarted 12-24 hours postoperatively once hemostasis is achieved, but this should be confirmed with the surgical team, taking into account the patient's individual risk factors and the presence of any epidural catheters 1.
• It's also important to monitor creatinine clearance postoperatively, especially if the patient's renal function could be affected by the surgery or their medical condition, and adjust the dose regimen of any direct oral anticoagulant (DOA) accordingly 1.
• The decision to hold or restart lovenox should always prioritize minimizing the risk of VTE while ensuring adequate hemostasis to prevent bleeding complications, considering the patient's overall clinical context and guidelines from recent studies 1.

From the Research

Holding Lovenox in Patients Scheduled for Hip Surgery

• The decision to hold Lovenox (enoxaparin) in patients scheduled for hip surgery depends on various factors, including the patient's individual risk of thromboembolism and bleeding, as well as the type of surgery being performed 2, 3, 4, 5.
• Studies have shown that enoxaparin is effective in preventing deep vein thrombosis (DVT) after hip replacement surgery, with a lower risk of major bleeding compared to unfractionated heparin 2, 4, 5.
• The American College of Chest Physicians recommends that patients undergoing hip replacement surgery receive thromboprophylaxis with enoxaparin or other low-molecular-weight heparins, unless contraindicated 3, 4.
• In general, it is recommended to hold Lovenox for at least 12 hours before surgery and resume it once hemostasis is achieved, usually within 24 hours 6.
• However, the optimal timing for holding Lovenox may vary depending on the patient's individual circumstances and the specific surgery being performed, and should be determined on a case-by-case basis 2, 3, 4, 5, 6.

Considerations for Holding Lovenox

• The risk of thromboembolism and bleeding should be carefully weighed when deciding whether to hold Lovenox in patients scheduled for hip surgery 2, 3, 4, 5.
• Patients with a high risk of thromboembolism, such as those with a history of DVT or pulmonary embolism, may require continued thromboprophylaxis with Lovenox throughout the perioperative period 3, 4.
• On the other hand, patients with a high risk of bleeding, such as those with renal or hepatic dysfunction, may require a longer period of time without Lovenox before surgery 2, 5.
• The use of local measures to achieve hemostasis, such as topical hemostatic agents or surgical techniques to minimize bleeding, may also be considered in patients who require continued thromboprophylaxis with Lovenox 6.

Clinical Evidence

• Studies have demonstrated the efficacy and safety of enoxaparin in preventing DVT after hip replacement surgery, with a lower risk of major bleeding compared to unfractionated heparin 2, 4, 5.
• A study published in the Archives of Orthopaedic and Trauma Surgery found that enoxaparin was as safe and effective as standard heparin in total hip replacement surgery 2.
• Another study published in The Journal of Trauma found that thromboprophylaxis with 60 mg enoxaparin daily, in split doses, starting before surgery, was safe and appropriate in patients with hip fractures 3.
• A pharmacoeconomic evaluation published in The Annals of Pharmacotherapy found that use of enoxaparin following total hip replacement may decrease the risk of DVT and length of hospital stay compared to unfractionated heparin 5.