Indications
Enoxaparin and dalteparin: Prevention of venous
thromboembolism (VTE) (deep vein thrombosis [DVT]
and/or pulmonary embolism [PE]) in surgical or medical
patients. Dalteparin only: Extended treatment of
symptomatic DVT and/or PE in patients with cancer.
Enoxaparin only: Treatment of DVT with or without
PE (with warfarin). Enoxaparin and dalteparin:
Prevention of ischemic complications (with aspirin)
from unstable angina and non-ST-segment-elevation
MI. Enoxaparin only: Treatment of acute ST-segmentelevation
MI (with thrombolytics or percutaneous coronary
intervention).
Action
Potentiate the inhibitory effect of antithrombin on factor
Xa and thrombin. Therapeutic Effects: Prevention
of thrombus formation.
Pharmacokinetics
Absorption: Well absorbed after subcut administration
(87% for dalteparin, 92% for enoxaparin).
Distribution: Unknown.
Metabolism and Excretion: Dalteparin—unknown;
enoxaparin—primarily eliminated renally.
Half-life: Dalteparin—2.1–2.3 hr; enoxaparin—
3–6 hr (all areqin renal insufficiency).
TIME/ACTION PROFILE (anticoagulant effect)
ROUTE ONSET PEAK DURATION
Dalteparin
subcut
rapid 4 hr up to 24 hr
Enoxaparin
subcut
unknown 3–5 hr 12 hr
Contraindications/Precautions
Contraindicated in: Hypersensitivity to specific
agents or pork products; cross-sensitivity may occur;
Some products contain sulfites or benzyl alcohol and
should be avoided in patients with known hypersensitivity
or intolerance; Active major bleeding; History of
heparin-induced thrombocytopenia; Dalteparin—regional
anesthesia during treatment for unstable angina/
non–Q-wave MI.
Use Cautiously in: Severe hepatic or renal disease
(adjust dose of enoxaparin if CCr 30 mL/min);
Women 45 kg or men 57 kg; Retinopathy (hypertensive
or diabetic); Untreated hypertension; Geri: May
haveqrisk of bleeding due to age-relatedpin renal
function; Dalteparin—Geri:qmortality in patients
70 yrs with renal insufficiency; Recent history of ulcer
disease; History of congenital or acquired bleeding disorder;
OB, Lactation, Pedi: Safety not established;
should not be used in pregnant patients with prosthetic
heart valves without careful monitoring.
Exercise Extreme Caution in: Spinal/epidural
anesthesia (qrisk of spinal/epidural hematomas, especially
with concurrent NSAIDs, repeated or traumatic
epidural puncture, or indwelling epidural catheter); Severe
uncontrolled hypertension; Bacterial endocarditis;
Bleeding disorders.
Adverse Reactions/Side Effects
CNS: dizziness, headache, insomnia. CV: edema. GI:
constipation,qliver enzymes, nausea, vomiting. GU:
urinary retention. Derm: alopecia, ecchymoses, pruritus,
rash, urticaria. Hemat: BLEEDING, anemia, eosinophilia,
thrombocytopenia. Local: erythema at injection
site, hematoma, irritation, pain. MS: osteoporosis.
Misc: fever.
Interactions
Drug-Drug: Risk of bleeding may beqby concurrent
use of drugs that affect platelet function and
coagulation, including warfarin, aspirin, NSAIDs,
dipyridamole, clopidogrel, abciximab, eptifibatide,
tirofiban, and thrombolytics.
Drug-Natural Products:qbleeding risk with arnica,
chamomile, clove, feverfew, garlic, ginger,
ginkgo, Panax ginseng, and others.
Route/Dosage
Dalteparin
Subcut (Adults): Prophylaxis of DVT following abdominal
surgery—2500 units 1–2 hr before surgery,
then once daily for 5–10 days; Prophylaxis of VTE in
high-risk patients undergoing abdominal surgery—
5000 units evening before surgery, then once daily for
5–10 days or in patients with malignancy, 2500 units
1–2 hr before surgery, another 2500 units 12 hr later,
then 5000 units once daily for 5–10 days; Prophylaxis
of VTE in patients undergoing hip replacement surgery—
2500 units within 2 hr before surgery, then
2500 units 4–8 hr after surgery, then 5000 units once
daily (start at least 6 hr after postsurgical dose) for 5–
10 days or 5000 units evening before surgery (10–14
hr before surgery), then 5000 units 4–8 hr after surgery,
then 5000 units once daily for 5–10 days or 2500
units 4–8 hr after surgery, then 5000 units once daily
(start at least 6 hr after postsurgical dose); Prophylaxis
of VTE in medical patients with severely restricted
mobility during acute illness: 5000 units once daily
for 12 to 14 days. Unstable angina/non–ST-segmentelevation
MI—120 units/kg (not to exceed 10,000
units) q 12 hr for 5–8 days with concurrent aspirin;
Extended treatment of symptomatic VTE in cancer
patients—200 units/kg (not to exceed 18,000 units)
once daily for first 30 days, followed by 150 units/kg
(not to exceed 18,000 units) once daily for mo 2–6.
Renal Impairment
Subcut (Adults): Cancer patients receiving extended
treatment of symptomatic VTE with CCr30
mL/min—Monitor anti-Xa levels (target 0.5–1.5 IU/
mL).
Enoxaparin
Subcut (Adults): VTE prophylaxis in patients undergoing
knee replacement surgery—30 mg q 12 hr
starting 12–24 hr postop for 7–10 days; VTE prophylaxis
in patients undergoing hip replacement surgery—
30 mg q 12 hr starting 12–24 hr postop or 40
mg once daily starting 12 hr before surgery (either
dose may be continued for 7–14 days; continued prophylaxis
with 40 mg once daily may be continued for up
to 3 wk); VTE prophylaxis following abdominal surgery—
40 mg once daily starting 2 hr before surgery
and then continued for 7–12 days or until ambulatory
(up to 14 days); VTE prophylaxis in medical patients
with acute illness—40 mg once daily for 6–14 days;
Treatment of DVT/PE (outpatient)—1 mg/kg q 12
hr. Warfarin should be started within 72 hr; enoxaparin
may be continued for a minimum of 5 days and until therapeutic anticoagulation with warfarin is achieved
(INR 2 for 2 consecutive days); Treatment of DVT/PE
(inpatient)—1 mg/kg q 12 hr or 1.5 mg/kg once
daily. Warfarin should be started within 72 hr; enoxaparin
may be continued for a minimum of 5 days and
until therapeutic anticoagulation with warfarin is
achieved (INR 2 for two consecutive days); Unstable
angina/non–ST-segment-elevation MI—1 mg/kg q
12 hr for 2–8 days (with aspirin).
IV, Subcut (Adults 75 yr): Acute ST-segment-elevation
MI—Administer single IV bolus of 30 mg plus 1
mg/kg subcut dose (maximum of 100 mg for first 2
doses only), followed by 1 mg/kg subcut q 12 hr. The
usual duration of treatment is 2–8 days. In patients undergoing
percutaneous coronary intervention, if last
subcut dose was 8 hr before balloon inflation, no additional
dosing needed; if last subcut dose was 8 hr
before balloon inflation, administer single IV bolus of
0.3 mg/kg.
Subcut (Adults 75 yr): Acute ST-segment-elevation
MI—0.75 mg/kg every 12 hr (no IV bolus
needed) (maximum of 75 mg for first 2 doses only; no
initial bolus). The usual duration of treatment is 2–8
days.
Renal Impairment
Subcut (Adults CCr 30 mL/min): VTE prophylaxis
for abdominal or knee/hip replacement surgery—
30 mg once daily. Treatment of DVT/PE—1 mg/kg
once daily. Unstable angina/non-ST-segment-elevation
MI—1 mg/kg once daily. Acute ST-segment-elevation
MI (patients75 yr)—Single IV bolus of 30
mg plus 1 mg/kg subcut dose, followed by 1 mg/kg subcut
once daily. Acute ST-segment-elevation MI (patients
75 yr)—1 mg/kg once daily (no initial bolus).
Availability
Dalteparin
Solution for injection (prefilled syringes): 2500
units/0.2 mL, 5000 units/0.2 mL, 7500 units/0.3 mL,
10,000 units/1 mL, 12,500 units/0.5 mL, 15,000 units/
0.6 mL, 18,000 units/0.72 mL. Solution for injection
(multidose vials): 25,000 IU/mL.
Enoxaparin (generic available)
Solution for injection (prefilled syringes): 30 mg/
0.3 mL, 40 mg/0.4 mL, 60 mg/0.6 mL, 80 mg/0.8 mL,
100 mg/1 mL, 120 mg/0.8 mL, 150 mg/mL.
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