Initiation and Maintenance

Initiation of enoxaparin therapy:

• Obtain blood for baseline CBC, PT, PTT.

• Calculate enoxaparin dose (mg) based on age, weight and indication. See Table 1.

Table 1 - Initial Dosing of Enoxaparin:

Maximum dose without a Hematology consult is 2 mg/kg q 12 hours.

Dosing for impaired renal function:

• If CrCl is < 30ml/min/1.73m², consider use of standard heparin as an alternative and consult Hematology for dosage recommendations.

Maintenance and monitoring of enoxaparin:

Table 2 - Target LMW heparin levels:

Table 3 - Adjustment of treatment dose and monitoring based on LMW heparin level:

• After initiation of therapy, the first LMW heparin level is drawn 4 hours after the 3rd dose of enoxaparin. Adjustment to the initial dose should not be made until the LMW heparin level obtained 4 hours after the 3rd dose is known.

• Enoxaparin dosing will be adjusted to standard administration times by nursing (8am & 8pm). This adjustment will be complete by the 3rd dose, so timing of lab draws for enoxaparin will usually be set for 1200 or 0000 depending on which time the 3rd dose would be given.

• If rapid anticoagulation is required the LMW heparin level may be drawn 4 hours after each dose until a therapeutic level is attained. [Rapid anticoagulation ONLY].

• Adjust treatment dose and further monitoring based on the LMW heparin level using Table 2.

• This table applies only if there is no bleeding.

• Additional monitoring is NOT required for prophylaxis dosing.

• Infants frequently require higher enoxaparin doses: up to 1.7 mg/kg for term infants and 2 mg/kg for preterm infants. Maximum dose without a Hematology consult is 2 mg/kg q 12 hours.
  
  

References

David, M., et al. (2007, Jan). Heparin and LMWH in Children. Thrombosis Interest Group of Canada. Retrieved Nov 15, 2018, from http://www.tigc.org/eguidelines/heparinchild07.htm. 


Lexicomp Online, Pediatric and Neonatal Lexi-Drugs. Enoxaparin. Retrieved Nov 2018, from https:online.lexi.com. 

Monagle, P., Chan, A. K. C., Goldenberg, N. A., Ichord, R. N., Journeycake, J. M., Nowak-Göttl, U., & Vesely, S. K. (2012). Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141(2 Suppl), e737S-e801S. https://doi.org/10.1378/chest.11-2308


Monagle, P., Cuello, C. A., Augustine, C., Bonduel, M., Brandão, L. R., Capman, T., Chan, A. K. C., Hanson, S., Male, C., Meerpohl, J., Newall, F., O'Brien, S. H., Raffini, L., van Ommen, H., Wiernikowski, J., Williams, S., Bhatt, M., Riva, J. J., Roldan, Y., . . . Vesely, S. K. (2018). American Society of Hematology 2018 Guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism. Blood Adv, 2(22), 3292-3316. https://doi.org/10.1182/bloodadvances.2018024786


Roach, E. S., Golomb, M. R., Adams, R., Biller, J., Daniels, S., Deveber, G., Ferriero, D., Jones, B. V., Kirkham, F. J., Scott, R. M., & Smith, E. R. (2008). Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke, 39(9), 2644-2691. https://doi.org/10.1161/strokeaha.108.189696