As part of my major research project this year, I have been working on updating our policies and recommendations for how we manage and monitor enoxaparin at HH. These changes aim to provide better guidance for pharmacists to optimize enoxaparin therapy based on anti-Xa levels and in obese patients. The updates can be broken down into three parts:

1. Adoption of Pharmacist-Led Anti-Xa Dosing Nomograms: 

• Nomograms to guide dosage adjustments for both therapeutic and prophylactic enoxaparin have been added to Sentri7 under Anticoagulation Medication Management --> Extended LOVENOX Therapy - Anticoag. 
• Ordering Levels:
• When to consider ordering: bleeding, new thrombosis, renal impairment/AKI, obesity, liver disease
• How to order: order 4-6 hours after at least the 3rd dose; leave open intervention until resulted; if additional levels warranted, recheck following at least 3 doses at new dose
• When anti-Xa levels are found to be abnormal, these nomograms should be used as a guide for dosage adjustments that have been P&T approved. 
• New doses should be entered with comma phrase ",dosept" ("Dose adjustment per P&T") with Cosign Required by provider. 

2. Maximum Initial Dose in Morbidly Obese Patients: 

• The maximum initial recommended treatment dose for morbidly obese patients will now be capped at 200 mg
• EXAMPLE: A 280 kg patient has a pulmonary embolus. The MD orders lovenox 1 mg/kg subcutaneous q12h. Cerner autocalculates the dose to be 280 mg subcutaneous q12h. 
• Per P&T, the Pharm.D. will change the dose to 200 mg subcutaneous q12h.
• Dose changes should be entered with comma phrase ",dosept" ("Dose adjustment per P&T") with No Cosign Required by provider.
• These patients should have anti-Xa levels drawn after three doses.
• NOTE: This is an infrequent occurrence, but we want to have guidance for when it occurs.

 

• At verification of prophylactic enoxaparin, the patient's height/weight should be reviewed to consider if increased prophylactic dosing is warranted. 
• For patients whose BMI ≥ 40 kg/m², prophylactic enoxaparin (40 mg daily) will be automatically converted to 40 mg q12h with comma phrase ",dosept" ("Dose adjustment per P&T") with No Cosign Required by provider. 
• Exclusions: 
• Trauma patients receiving 30 mg q12h
• Renal insufficiency requiring 30 mg q24h prophylactic dosing.

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Additionally, you may have noticed a new Sentri7 tab that was recently activated. It can be found under Anticoagulation Medication Management --> Lovenox with BMI > 40 or dose > 200 mg q12h. This rule identifies patients with a BMI > 40 kg/m² who have been receiving enoxaparin for at least 24 hours (excluding trauma prophylaxis and renally adjusted prophylaxis dosing). Pharmacists should review patients who are being captured by this rule to ensure height/weight are accurate and that a patient truly does have a BMI > 40 kg/m². If the patient is receiving therapeutic (1 mg/kg q12h) dosing, an anti-Xa level should be ordered for 4-6 hrs following the 3rd or 4th dose with an open intervention left for follow-up. If the patient is receiving 40 mg q24h, pharmacists may automatically convert the patient to 40 mg q12h prophylaxis dosing as described above.