Enoxaparin

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[edit] BRAND NAMES

[edit] MECHANISM OF ACTION

Enoxaparin is a low molecular weight heparin (LMWH) with antithrombotic properties. LMWHs inhibit the coagulation process through binding to antithrombin (AT). This binding leads to a conformational change of AT which accelerates its inhibition of thrombin (factor IIa) and activated factor X (factor Xa).

In humans, Enoxaparin potentiates preferentially the inhibition of coagulation Factor Xa. Factor Xa catalyzes the conversion of prothrombin to thrombin, so Enoxaparin's inhibition of this process results in decreased thrombin and ultimately the prevention of fibrin clot formation.

LMWHs have a reduced potential to cause bleeding compared with unfractionated heparin (UFH).

[edit] INDICATIONS

  • Prophylaxis of deep vein thrombosis (DVT):
    • Medical: For patients who are at risk for thromboembolic complications due to severely restricted mobility during acute illness.
    • Orthopedics: In patients undergoing hip replacement surgery.
    • Surgery: In patients undergoing abdominal surgery who are at risk for thromboembolic complications.
  • Treatment of Acute Deep Vein Thrombosis
    • the inpatient treatment of acute deep vein thrombosis with or without pulmonary embolism, when administered in conjunction with warfarin sodium.
    • the outpatient treatment of acute deep vein thrombosis without pulmonary embolism when administered in conjunction with warfarin sodium.
  • Prophylaxis of ischemic complications of unstable angina and non-Q-wave myocardial infarction (NQWMI) when concurrently administered with aspirin therapy
  • Treatment of Acute ST-Segment Elevation Myocardial Infarction: Enoxaparin when administered concurrently with aspirin, has been shown to reduce the rate of the combined endpoint of recurrent myocardial infarction or death in patients with acute ST-segment elevation myocardial infarction (STEMI) receiving thrombolysis and being managed medically or with percutaneous coronary intervention (PCI)

[edit] DOSAGE

Indication Dosing Regimen
Unstable angina and non-Q-wave MI
1 mg/kg subcutaneous every 12
hours (with aspirin)
DVT prophylaxis in abdominal surgery
40 mg subcutaneous once daily 

DVT prophylaxis in hip replacement
surgery

30 mg subcutaneous every 12 hours or 40 mg subcutaneous once daily

DVT prophylaxis in knee replacement
surgery
30 mg subcutaneous every 12 hours
DVT prophylaxis in medical patients with severely restricted mobility during acute illness 40 mg subcutaneous once daily
inpatient treatment of acute deep vein thrombosis with or without pulmonary embolism
1 mg/kg subcutaneous every 12
hours or 1.5 mg/kg subcutaneous once daily
Outpatient treatment of acute deep vein thrombosis without pulmonary embolism 1 mg/kg subcutaneous every 12 hours
Acute STEMI in patients <75 years of age 30 mg single IV bolus plus a 1 mg/kg SC dose followed by 1 mg/kg SC every 12 hours at least 8 days (with aspirin)
Acute STEMI in patients ≥75 years of age 0.75 mg/kg SC every 12 hours (no bolus) at least 8 days (with aspirin)

Enoxaparin should not be used as intramuscular injection.

[edit] CONTRAINDICATIONS

  • Active major bleeding
  • Thrombocytopenia with a positive in vitro test for anti-platelet antibody in the presence of enoxaparin
  • Hypersensitivity to enoxaparin
  • Hypersensitivity to heparin or pork products

[edit] WARNINGS AND PRECAUTIONS

  • SPINAL/EPIDURAL HEMATOMA: Epidural or spinal hematomas may occur in patients who are anticoagulated with low molecular weight heparins (LMWH) or heparinoids and are receiving neuraxial anesthesia or undergoing spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients for spinal procedures. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include:
    • Use of indwelling epidural catheters
    • Concomitant use of other drugs that affect hemostasis, such as nonsteroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants
    • A history of traumatic or repeated epidural or spinal punctures
    • A history of spinal deformity or spinal surgery

Patients should be monitored frequently for signs and symptoms of neurological impairment. If neurological compromise is noted, urgent treatment is necessary. benefits and risks shoud be also considered before neuraxial intervention in patients anticoagulated or to be anticoagulated for thromboprophylaxis

  • Increased risk of hemorrhage: Use with caution in patients at risk
  • Percutaneous coronary revascularization: Obtain hemostasis at the puncture site before sheath removal
  • Concomitant medical conditions: Use with caution in patients with bleeding diathesis, uncontrolled arterial hypertension or history of recent gastrointestinal ulceration, diabetic retinopathy, renal dysfunction, or hemorrhage
  • History of heparin-induced thrombocytopenia: Use with caution
  • Thrombocytopenia: Monitor thrombocytopenia closely
  • Interchangeability with other heparins: Do not exchange with heparin or other LMWHs
  • Pregnant women with mechanical prosthetic heart valves and their fetuses, may be at increased risk and may need more frequent monitoring and dosage adjustment

[edit] INTERACTIONS

Whenever possible discontinue agents which may enhance hemorrhage risk prior to initiation of Enoxaparin or conduct close clinical and laboratory monitoring.

[edit] PREGNANCY AND LACTATION

  • Pregnancy Category B (US)
  • Nursing Mothers: It is not known whether Enoxaparin is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from Enoxaparin , a decision should be made whether to discontinue nursing or discontinue Enoxaparin, taking into account the importance of Enoxaparin to the mother and the known benefits of nursing.

[edit] SIDE EFFECTS

Most common adverse reaction is hematoma at the injection site, bleeding, anemia, thrombocytopenia, elevation of serum aminotransferase, diarrhea, and nausea

[edit] RELATED LINKS

[edit] BIBLIOGRAPHY

[edit] REFERENCES