Patients with pulmonary embolism usually require inpatient therapy, according to the PERT Consortium. Anticoagulation should be started immediately in the case of suspected or proven pulmonary embolism. ![]() ![]() Treatment of Acute Deep Vein Thrombosis with or without Pulmonary Embolism: The recommended dose of enoxaparin is 1 mg/kg SC every 12 hours or 1.5 mg/kg SC daily. Venous Thromboembolism Prophylaxis: Recommended dose of enoxaparin is 40 mg SC once daily, according to the ACCP(American College of Chest Physicians) clinical practice guidelines. The dose of enoxaparin depends upon indications, adverse events profile, and renal/hepatic impairment. One mg of enoxaparin is equal to 100 units of anti-Xa activity. Intramuscular administration is generally avoided. There is a small risk of bruising that can be minimized by not rubbing the injection site. Subcutaneous administration should alternate between the left or right anterolateral and left or right posterolateral abdominal wall. An IV injection is usually given during the primary PCI and at the time of STEMI. The port should be flushed before use with normal saline or 5% dextrose water. The intravenous formulation should not be mixed or co-administered with other medications. Enoxaparin can also be administered in intravenous formulations. Ninety percent of the drug is available when given in the subcutaneous form. Įnoxaparin has an advantage over heparin because of its bioavailability. As enoxaparin is primarily eliminated by renal excretion, there is a concern for drug accumulation and bleeding risk in patients with renal impairment. Metabolism: It is metabolized in the liver by desulfation and depolymerization to lower molecular weight fragments with reduced biologic activity.Įxcretion: Enoxaparin follows first-order kinetics and is eliminated primarily in the urine. The elimination half-life of enoxaparin is approximately 3 to 4.5 hours following a single dose. Following repeated doses, the half-life of enoxaparin increases to approximately 7 hours. ĭistribution: The apparent volume of distribution of enoxaparin estimated by anti-Factor-Xa activity is approximately 4.3 Liters. Anti-Factor Xa activity is detected in plasma for about 12 hours. Ībsorption: Peak effect of enoxaparin is observed approximately 4 hours after administration. The anti-factor Xa-to-IIa activity ratio for the LMWHs varies from 2:1 to 4:1. Thus, enoxaparin has less activity against factor IIa (thrombin) than unfractionated heparin. Due to their smaller chain length and lower molecular weight, LMWH has better activity against factor-Xa and inhibits thrombin to a lesser degree. Smaller heparin fragments cannot bind antithrombin and thrombin simultaneously. The primary difference between unfractionated heparin and enoxaparin is their relative inhibition of thrombin (factor-IIa) and factor-Xa. Enoxaparin is an indirect anticoagulant that binds and potentiates antithrombin III (serine protease inhibitor) through a specific pentasaccharide sequence to form a complex that irreversibly inactivates factor Xa. It has a quick onset of action when given in the intravenous form. ![]() All rights reserved.Enoxaparin is low molecular weight heparin (LMWH) with a mean molecular weight of 4000 to 5000 Daltons. With the availability of anti-Xa assays, future reversal recommendations of enoxaparin associated bleeds using protamine sulfate should include the initial anti-Xa assay as a guide for the dosing regimen.Įnoxaparin Pharmacology Protamine sulfate Resuscitation Toxicology.Ĭopyright © 2018 Elsevier Inc. Our case demonstrates the importance of monitoring renal function and the potential for accumulation of enoxaparin in patients with renal dysfunction leading to prolonged therapeutic anti-Xa assays. Along with resuscitative efforts, an interdisciplinary team collaborated to administer protamine sulfate 50 mg intravenous once (0.5 mg per 1 mg of enoxaparin) to reverse the therapeutic anticoagulation. We present a case of a hemodynamically unstable patient with an enoxaparin induced abdominal wall hematoma/hemorrhage and the previous enoxaparin administration 21.5 h prior to presentation with a therapeutic anti-Xa assay (0.8 IU/mL) upon assessment in the emergency department. Clinical practice guidelines recommend protamine sulfate for reversal of enoxaparin associated bleeds dependent on the time from last administration and dose of enoxaparin.
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