• Check FBC, INR and APTT, U&E, LFT
• Always weigh patient
  
  • use actual body weight to calculate prescribed dose
  • do NOT guess body weight or rely on patient’s own estimate
• Assess risk of bleeding (see Relative contraindications)
• Consider need for monitoring, especially heparin-induced thrombocytopenia or anti-Xa monitoring (see Monitoring enoxaparin treatment)

• Acute bacterial endocarditis
• Major trauma
• Epidural and spinal anaesthesia
• Haemophilia or other haemorrhagic disorders
• Recent: 
  
  • major gastrointestinal (GI) bleed
  • cerebral haemorrhage
  • surgery to eye/nervous system
• Thrombocytopenia 
• Suspected/confirmed/previous heparin induced thrombocytopenia - see Heparin Induced Thrombocytopaenia (HIT) guideline for alternative non heparin anticoagulant options

VTE treatment in non-pregnant adult patients with CrCl ≥30 mL/min

• Commence enoxaparin 1 mg/kg 12-hrly (see Table 1) if any of the following risk factors apply:
  
  • obesity (BMI >30)
  • symptomatic pulmonary embolism (PE)
  • active cancer (see Extended treatment of enoxaparin in non-pregnant patients with active cancer)
  • recurrent VTE
  • thrombosis of popliteal vein and above 
• Prescribe lower dose 1.5 mg/kg once daily (see Table 2) in patients with any of the following:
  
  • incidental VTE with no other risk factors
  • thrombosis below popliteal vein with no other risk factors
  • higher risk of bleeding which outweighs likelihood of VTE recurrence
  • superficial vein thrombosis (SVT) within 3 cm of the deep system

Non-pregnant adult patients with CrCl <30 mL/min (renal dosing)

• If CrCl <30 mL/min: enoxaparin 1 mg/kg once daily (see Table 3)
• Dosing in renal impairment remains unchanged irrespective of associated risk factors
• If CrCl <15 mL/min and receiving treatment dose enoxaparin >7 days: monitor anti-factor Xa
• Seek advice from renal and/or Staffordshire thrombosis and anticoagulation centre (STAC)

Extended treatment of enoxaparin in non-pregnant patients with active cancer

• If CrCl ≥30 mL/min: enoxaparin 1 mg/kg 12-hrly for 10 days, then 
  
  • 1.5 mg/kg daily for 6 months 
• If CrCl <30 mL/min: enoxaparin 1 mg/kg daily for 6 months

HIT

• In a medical patient who has not received unfractionated heparin, monitoring for heparin-induced thrombocytopenia not required
• If patient is being, or has (in last 3 months) been, treated with unfractionated heparin, or is a post-operative surgical patient being treated with low molecular weight heparin (LMWH): 
  
  • check platelet count on alternate days starting from day 4 until day 14 of heparin treatment
    
    • if patient has been given heparin in preceding 100 days, from day 2 
  • compare platelet count with pre-treatment result - see Heparin Induced Thrombocytopaenia (HIT) guideline

Anti-Xa monitoring

• If weight <50 kg or >90 kg, or patient has bleeding problems, CrCl <15 mL/min, or massive PE, discuss need for anti-Xa monitoring with STAC

• See Table 1
• Use in complicated VTE where any of the following risk factors apply:
  
  • obesity (BMI >30)
  • symptomatic PE
  • active cancer (see Extended treatment of enoxaparin in non-pregnant patients with active cancer)
  • recurrent VTE
  • thrombosis of popliteal vein and above

Dosing and administration

• Enoxaparin
  
  • 60 mg/0.6 mL, 80 mg/0.8 mL and 100 mg/1 mL: 10 mg per 0.1 mL
  • 120 mg/0.8 mL and 150 mg/1 mL: 15 mg per 0.1 mL

Table 1

• See Table 2
• Use in uncomplicated VTE where any of the following apply:
  
  • incidental VTE with no other risk factors
  • thrombosis below the popliteal vein with no other risk factors
  • higher risk of bleeding which outweighs the likelihood of VTE recurrence
  • SVT within 3 cm of the deep system

Dosing and administration

• Enoxaparin
  
  • 60 mg/0.6 mL, 80 mg/0.8 mL and 100 mg/1 mL: 10 mg per 0.1 mL
  • 120 mg/0.8 mL and 150 mg/1 mL: 15 mg per 0.1 mL

Table 2

• See Table 3
• If CrCl <15 mL/min: monitor anti-factor Xa if receiving treatment dose enoxaparin >7 days
  
  • seek advice from STAC

Dosing and administration

• Enoxaparin
  
  • 60 mg/0.6 mL, 80 mg/0.8 mL and 100 mg/1 mL: 10 mg per 0.1 mL
  • 120 mg/0.8 mL and 150 mg/1 mL: 15 mg per 0.1.mL

Table 3