Approved Hospital Formulary
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Approved Hospital Formulary
5/10/22 js Enoxaparin Dosing Nomogram and Obesity Considerations
May 16, 2022
From: "Jackson Spradlin" <jackson.spradlin@hhsys.org>
To: "Pharmacists" <grp_allpharm@hhsys.org>
Cc: "Monroe Crawley" <monroe.crawley@hhsys.org>
Sent: Tuesday, May 10, 2022 12:45:54 PM
Subject: Re: Enoxaparin Dosing Nomogram and Obesity Considerations
Hey, everyone!
Now that the enoxaparin policy update has made its way through P&T and various other committees, I wanted to provide you all with some info regarding specific changes to the policy and clarifications from questions I have received. I've summarized them below.
1. Anti-Xa Levels and Liver Dysfunction
- Anti-Xa levels should not be used to up-titrate dosing in patients with acute or chronic liver failure due to concern for falsely low values and potential risks associated with dose escalation in these patients.
- Routine anti-Xa levels should be avoided unless there are suspicions for increased enoxaparin exposure or concerns for bleeding.
- Therefore, do NOT uptitrate enoxaparin dosing based on low anti-Xa levels in these patients using the approved dosing nomograms.
- Work with provider regarding any clinical concerns or changes to enoxaparin regimen.
2. Prophylactic Dosing in Patient with BMI > 40 kg/m2
- We have narrowed the patient population that will qualify for the increased prophylactic doses of 40 mg q12h.
- Post-operative surgery (ortho, trauma, CV, and general) patients will be excluded due to the potential risk of bleeding complications.
- Continue verifying any prophylactic enoxaparin orders in these patients as you have been (i.e., renal adjustments).
3. Anti-Xa Monitoring in Patients with BMI > 40 kg/m2
- Patients receiving therapeutic enoxaparin dosing (1 mg/kg q12h) who are captured by the new Sentri7 rule should have anti-Xa levels checked (following 3rd-4th dose) to ensure dose is appropriate.
- Patients receiving prophylactic dosing (40 mg q12h, when appropriate) do NOT require routine anti-Xa monitoring. An anti-Xa level can be checked if there is clinical concern for abnormal values (e.g., AKI, thrombosis, bleed, etc.).
4. Pregnancy/Pediatrics
- All of the policy updates are limited to adult, non-pregnant patients.
- At the request of some of the OBGYN providers, I have included some enoxaparin dosing strategies that may be recommended to a provider, if needed. I have also included target anti-Xa levels for pregnant patients. These have been included for reference.
- Do not make any automatic adjustments based on BMI or anti-Xa levels to enoxaparin orders in a pregnant or pediatric patient. Contact the provider if there are clinical concerns.
- Renal dose adjustments still apply.
Thanks!