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Enoxaparin ā prescribing, administration and monitoring (adults) ā clinical guideline, v2 Authors: Alice Foster, Gareth Malson Approved by MCGT February 2016 Review by: February 2019
Clinical guideline
Enoxaparin ā prescribing, administration and monitoring
Enoxaparin is the low molecular weight heparin (LMWH) used at WUTH. This guideline covers the following:
- Indications 2. Contraindications 3. Initiation and dose
- Duration 5. Administration 6. Monitoring
- Reversal 8. Discharge 9. Other guidelines
- References Appendix: Dose banding
This document is a guideline and further information should be obtained from the relevant reference sources.
1. Indications (see Table 1) ļ· Venous thromboembolism (VTE) prophylaxis ļ· Venous thromboembolism (VTE) treatment ļ· Acute coronary syndrome (ACS)
There are specific guidelines for managing VTE prophylaxis and treatment in: ļ· Maternity ā for all patients who are pregnant and up to 6 weeks post-partum ļ· Trauma and Orthopaedics
2. Contraindications:
Enoxaparin is contraindicated in patients with: ļ· acute bacterial endocarditis ļ· active major bleeding and conditions with a high risk of uncontrolled haemorrhage, including recent haemorrhagic stroke; ļ· recent thrombotic stroke (should not be used for 14 days due to risk of haemorrhagic transfer) ļ· thrombocytopenia in patients with a positive in-vitro aggregation test in the presence of enoxaparin (heparin-induced thrombocytopenia [HIT]); ļ· active gastric or duodenal ulceration; ļ· hypersensitivity to either enoxaparin sodium, heparin or its derivatives ā including other LMWHs; ļ· Platelet count less than 75 x 10^9 /L (refer to haematology if platelets are below this level and treatment is deemed clinically essential)
3. Initiation
The dose and choice of drug is dependent on the patientās renal function (creatinine
clearance [CrCl]) and weight. Check renal function using Cockcroft and Gault. Renal
function using eGFR is not equivalent to CrCl and cannot be used for dose adjustment in renal impairment. A CrCl calculator is available on the intranet: http://apps.wuth.nhs.uk/staff/formulary/calculators.aspx
Enoxaparin ā prescribing, administration and monitoring (adults) ā clinical guideline, v2 Authors: Alice Foster, Gareth Malson Approved by MCGT February 2016 Review by: February 2019
Cockcroft and Gault equation for creatinine clearance:
Creatinine clearance (mL/min) = Y x (140-age) x weight^ (kg)^ Male Y= 1. Serum creatinine (Ī¼mol/L) Female Y=1. ļ· Use ideal body weight (IBW) in patients unless over or under weight: IBW Females = [45.5kg + (2.3 x every inch over 5ft)] kg IBW Males = [50kg + (2.3 x every inch over 5ft)] kg ļ· Use adjusted body weight in obese patients = IBW + 0.4 x (actual body weight ā IBW) kg ļ· Use actual body weight in underweight patients
VTE assessment to be completed on CERNER for all adult inpatients before enoxaparin prescribed for prophylaxis.
Table 1: Indication for use of enoxaparin (For alternatives, see specific guidelines for āMaternityā and āTrauma and Orthopaedicsā)
*For 5 days minimum and until INR in range for 2 consecutive days where warfarin is initiated.
****Extremes of actual body weight and VTE prophylaxis** : <50kg ā use 20mg enoxaparin once daily 100-150kg ā use 80mg enoxaparin once daily
150kg ā use 120mg enoxaparin once daily ĒActual body weight should be used for dose calculation. See Appendix 1 for dose banding.
Indication Clinical situation Dose drug and frequency Renal dose and frequency
VTE prophylaxis (Also see specific VTE guidelines for āMaternityā and āTrauma and Orthopaedicsā)
Medical patient (^) Enoxaparin 40mg** once daily (^) CrCl<30ml/minute enoxaparin 20mg once daily
Surgical patient high risk Surgical patient moderate risk
Enoxaparin 20mg** once daily Elective hip replacement
Rivaroxaban 10mg once daily for 35 days
CrCl<15ml/minute enoxaparin 20mg once daily for 35 days Elective knee replacement
Rivaroxaban 10mg once daily for 14 days
CrCl<15ml/minute enoxaparin 20mg once daily for 14 days VTE treatment
All non-pregnant patients
Enoxaparin 1.5mg/kgĒ once daily*
CrCl<30ml/minute enoxaparin 1mg/kgĒ^ once daily
ACS
Prophylaxis
Fondaparinux 2.5mg once daily for 8 days then switch to enoxaparin
CrCl<20ml/minute enoxaparin 1mg/kgĒ^ once daily Full anticoagulationā in patients UNDER 75 years old
Enoxaparin 1mg/kgĒ^ twice daily
CrCl<30ml/minute enoxaparin 1mg/kgĒ^ once daily Full anticoagulationā in patients OVER 75 years old
Enoxaparin 0.75mg/kgĒ twice daily
CrCl<30ml/minute enoxaparin 1mg/kgĒ^ once daily
Enoxaparin ā prescribing, administration and monitoring (adults) ā clinical guideline, v2 Authors: Alice Foster, Gareth Malson Approved by MCGT February 2016 Review by: February 2019
7. Reversal
Within 5 minutes of being administered, protamine acts to neutralise the effects of enoxaparin. However, at maximum, it only neutralises 60% of enoxaparinās effect. The dose depends on the time since the enoxaparin was given:
ļ· If enoxaparin given LESS than 5 hours ago, give 1mg protamine for every 1mg enoxaparin administered ļ· If enoxaparin given MORE than 5 hours ago, give 0.5mg protamine for every 1mg enoxaparin administered
Patients should be carefully monitored using either the activated partial thromboplastin time or the activated clotting time ā carried out 5-15 minutes after protamine administration. Further doses may be needed because protamine is cleared from the blood more rapidly than heparin, especially low molecular weight heparin. In gross excess, protamine itself acts as an anticoagulant.
8. Discharge
Where enoxaparin is prescribed on discharge, the prescriber must provide clear instructions to the patientās GP regarding the dose of enoxaparin and the duration of treatment. Where treatment is intended to last longer than 6 weeks, a referral to haematology must be made to ensure ongoing monitoring.
When clinically checking the discharge prescription, at minimum, the ward pharmacist must ensure that the above information has been completed by the prescriber and is available on the discharge letter. The ward pharmacist should then complete the checklist below and endorse āIDDAMā on the discharge prescription to indicate that the above checks are complete before any supplies of LMWH will be made on discharge. Up to 2 weeksā supply of LMWH will be made by the hospital at discharge and then this should be continued by the patientās GP. ļ· Appropriate I ndication (if on extended duration of LMWH due to poor compliance, must state in the notes that the decision has been approved by the senior medical staff) ļ· D ose ā appropriate for the patientās renal function and weight ļ· D uration ļ· Appropriately trained person to A dminister the LMWH in the community if the patient is unable to self-administer. ļ· M onitoring. The patient has been referred to haematology by the clinician for ongoing monitoring for patientās receiving extended LMWH treatment
levels Bone densitometry
Enoxaparin ā prescribing, administration and monitoring (adults) ā clinical guideline, v2 Authors: Alice Foster, Gareth Malson Approved by MCGT February 2016 Review by: February 2019
9. Other related trust guidance
Other guidelines relating to anticoagulation can be found under āanticoagulationā within the clinical guidelines section of the Medicines Management website.
10. References
- National Institute for Health and Clinical Excellence (NICE) clinical guidelines 92: Venous thromboembolism: reducing the risk. Issue date: January 2010. Available at: www.nice.org.uk/guidance/index.jsp?action=byID&o=12695 (accessed 1/6/2015)
- Department of Health. Venous thromboembolism risk assessment tool http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_co nsum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113355.pdf (accessed 1/6/2015)
- Summary of product characteristics. Clexane. http://www.medicines.org.uk/emc/medicine/12847 (accessed 1/6/2015)
- British National Formulary May 2015 online https://www.medicinescomplete.com/mc/bnf/current/ (accessed 1/6/2015)
- WUTH Maternity guidelines http://www.whnt.nhs.uk/document_uploads/Intranet- Pharmacy/VTE%20Guideline_(maternity)-clinical_guideline,v6.pdf
- WUTH Trauma and Orthopaedic http://www.wuth.nhs.uk/media/1567932/VTE_prophylaxis_Trauma-and- orthopaedics_v23.pdf
- WUTH http://www.wuth.nhs.uk/media/1567959/Heparin-induced-thrombocytopenia-HIT- Diagnosis-and-management-v1.pdf
- Anticoagulant Guidelines Kings College Hospital http://www.kingsthrombosiscentre.org.uk/index.php/anticoagulation/anticoagulation- guidelines (accessed online 1/6/2015)
- Summary of product characteristics protamine sulphate 1% http://www.medicines.org.uk/emc/medicine/10807/spc (accessed 8/6/2015)
