enoxaparin (Rx)

Brand and Other Names:Lovenox
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

multidose vial

  • 100mg/mL (3mL vial)

prefilled syringe

  • 30mg/0.3mL
  • 40mg/0.4mL
  • 60mg/0.6mL
  • 80mg/0.8mL
  • 100mg/mL
  • 120mg/0.8mL
  • 150mg/mL

Deep Vein Thrombosis (Prophylaxis)

Patients at risk undergoing abdominal surgery or hip or knee replacement surgery, as well as patients with severely restricted mobility during acute illness

Abdominal surgery

  • 40 mg SC qDay; initiate 2 hr preoperatively

Knee or hip replacement surgery

  • 30 mg SC q12hr; initiate therapy 12-24 hr postoperatively; continue for 10 days, or up to 35 days postoperatively, or risk of DVT reduced significantly, or patient is on anticoagulant therapy
  • For hip replacement surgery, may administer 40 mg SC qDay; initiate 9-15 hr preoperatively; continue for 10 days, or up to 35 days postoperatively, or until risk of DVT reduced significantly, or patient is on anticoagulant therapy

Medical patients with restricted mobility

  • 40 mg SC qDay; continue until risk of DVT reduced significantly (6-11 days), or patient is on anticoagulant therapy

Dosing considerations

  • Abdominal surgery: Duration of administration is 7-10 days; up to 12 days has been administered in clinical trials or until risk of DVT has diminished
  • Knee or hip replacement surgery: Duration of administration is 7-10 days; up to 14 days has been administered in clinical trials or until risk of DVT has diminished
  • Medical patients with restricted mobility: Duration of administration is 6-11 days; up to 14 days has been administered in clinical trials

Deep Vein Thrombosis (Treatment)

Inpatient treatment

  • Acute DVT with or without PE, when administered in conjunction with warfarin sodium
  • 1 mg/kg SC q12hr, OR 1.5 mg/kg SC qDay (administer at same time each day)  

Outpatient treatment

  • Acute DVT without PE, when administered in conjunction with warfarin sodium
  • 1 mg/kg SC q12hr

Dosing considerations

  • In inpatient and outpatient treatments, initiate warfarin therapy within 72 hours of starting enoxaparin
  • Continue enoxaparin for a minimum of 5 days and until a therapeutic oral anticoagulant effect has been achieved (INR 2.0-3.0)
  • Average duration of administration is 7 days; up to 17 days has been administered in clinical trials

Unstable Angina & Non-Q-Wave MI

Prophylaxis of ischemic complications of unstable angina and non-Q-wave myocardial infarction, when concurrently administered with aspirin

1 mg/kg SC q12hr  

Regimen includes aspirin (100-325 mg/day PO)

Dosing considerations

  • Administer for at least 2 days and then continue until clinical stabilization
  • Usual duration of treatment is 2-8 days; up to 12.5 days has been administered in clinical trials

Acute Coronary Syndromes

Non-ST elevation myocardial infarction (NSTEMI): 1 mg/kg SC q12hr; coadminister with antiplatelet therapy; continue for duration of hospitalization or until percutaneous coronary intervention (PCI) performed

ST elevation myocardial infarction (STEMI): All patients should receive aspirin as soon as they are identified as having STEMI and should be maintained with 75-325 mg PO qDay unless contraindicated

<75 years

  • Loading dose: 30 mg IV bolus once plus 1 mg/kg SC once; not to exceed 100 mg cumulative loading dose  
  • Maintenance: 1 mg/kg SC q12hr

>75 years

  • No IV bolus
  • 0.75 mg/kg SC q12hr
  • Not to exceed 75 mg/dose for first 2 doses only, followed by 0.75 mg/kg for remaining doses

With PCI

  • If last enoxaparin was given <8 hr before balloon inflation, no additional dosing is needed
  • If last enoxaparin was given 8-12 hr before balloon inflation, an IV bolus of 0.3 mg/kg should be administered  
  • If PCI occurs >12 hr after last SC dose; use established anticoagulation therapy (full-dose unfractionated heparin or LMWH
  • Patient that has not received prior anticoagulant therapy: 0.5-0.75 mg/kg bolus dose

Dosing considerations

  • Administered concurrently with aspirin
  • In conjunction with thrombolytic: Administer enoxaparin between 15 minutes before and 30 minutes after initiating fibrinolytic therapy; optimal treatment duration of enoxaparin is 8 days or until hospital discharge (whichever comes first)

Dosing Modifications

Renal impairment

  • Severe (CrCl <30 mL/min): Dosage reductions required
  • Prophylaxis in abdominal surgery: 30 mg SC qDay
  • Prophylaxis in hip or knee replacement surgery: 30 mg SC qDay
  • Prophylaxis in medical patients with restricted mobility: 30 mg SC qDay
  • DVT treatment (inpatient or outpatient) coadministered with warfarin: 1 mg/kg SC qDay
  • Non-Q-wave myocardial infarction: 1 mg/kg SC qDay
  • Treatment of acute STEMI (<75 years): 30 mg IV single bolus plus 1 mg/kg SC, THEN 1 mg/kg SC qDay
  • Treatment of acute STEMI (>75 years): No initial bolus; maintenance of 1 mg/kg SC qDay

Administration

Low body weight (<45 kg for women or <57 kg for men): Increased exposure has been observed with prophylactic (non-weight adjusted) dosage; carefully monitor for sign/symptoms of bleeding

Administer deep SC alternating right and left anterior and posterior abdominal walls into skin fold held between thumb and forefinger

Use of tuberculin syringe (or equivalent) is recommended to assure appropriate measurement of dose

For IV administration, may administer in IV line with 0.9% NaCl or D5W

Dosage Forms & Strengths

multidose vial

  • 100mg/3mL

prefilled syringe

  • 30mg/0.3mL
  • 40mg/0.4mL
  • 60mg/0.6mL
  • 80mg/0.8mL
  • 100mg/mL
  • 120mg/0.8mL
  • 150mg/mL

Deep Vein Thrombosis (Off-label)

Prophylaxis

  • <2 months: 0.75 mg/kg SC q12hr  
  • ≥2 months: 0.5 mg/kg SC q12hr

Treatment

  • <2 months: 1.5 mg/kg SC q12hr
  • ≥2 months: 1 mg/kg SC q12hr

Dose Titration for Pediatric Dosing Based on Anti-Factor Xa Concentrations

  • <0.35 units/mL: Increase dose by 25%; administer next dose at scheduled time; repeat anti-factor Xa level 4 hr after next dose
  • 0.35-0.46 units/mL: Increase dose by 10%; administer next dose at scheduled time; repeat anti-factor Xa level 4 hr after next dose
  • 0.5 - 1 units/mL: Dose adjustment not necessary; administer next dose at scheduled time; repeat anti-factor Xa level every other day
  • 1.1-1.5 units/mL: Decrease dose by 20%; administer next dose at scheduled time; repeat anti-factor Xa level 4 hr after next dose
  • 1.6-2 units/mL: Decrease dose by 30%; delay next dose 3 hr; repeat anti-factor Xa level 4 hr after next dose
  • >2 units/mL: Decrease dose by 40%; delay next dose until anti-factor Xa <0.5 units/mL; repeat anti-factor Xa level before next dose and every 12 hr until anti-factor Xa <0.5 units/mL

Dosing considerations

  • Multidose vial contains benzyl alcohol, which is associated with gasping syndrome in premature infants

Increased risk of bleeding with doses of 1.5 mg/kg/day or 1 mg/kg q12hr  

Dosing considerations

Risk of serious adverse reactions increases in the elderly

Body weight <45 kg may require dose adjustment

Next:

Interactions

Interaction Checker

and enoxaparin

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            Contraindicated (3)

            • defibrotide

              defibrotide increases effects of enoxaparin by pharmacodynamic synergism. Contraindicated. Coadministration of defibrotide is contraindicated with antithrombotic/fibrinolytic drugs. This does not include use for routine maintenance or reopening of central venous lines.

            • mifepristone

              mifepristone, enoxaparin. Other (see comment). Contraindicated. Comment: Mifepristone may lead to excessive post abortion bleeding in pts. on anticoagulant therapy.

            • prothrombin complex concentrate, human

              enoxaparin, prothrombin complex concentrate, human. pharmacodynamic antagonism. Contraindicated.

            Serious - Use Alternative (64)

            • abciximab

              enoxaparin, abciximab. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • amobarbital

              amobarbital decreases effects of enoxaparin by increasing metabolism. Avoid or Use Alternate Drug.

            • anagrelide

              enoxaparin, anagrelide. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • antithrombin alfa

              antithrombin alfa and enoxaparin both increase anticoagulation. Avoid or Use Alternate Drug.

            • antithrombin III

              antithrombin III and enoxaparin both increase anticoagulation. Avoid or Use Alternate Drug.

            • apixaban

              enoxaparin and apixaban both increase anticoagulation. Avoid or Use Alternate Drug.

            • argatroban

              argatroban and enoxaparin both increase anticoagulation. Avoid or Use Alternate Drug.

            • azithromycin

              azithromycin increases effects of enoxaparin by decreasing metabolism. Avoid or Use Alternate Drug.

            • bazedoxifene/conjugated estrogens

              bazedoxifene/conjugated estrogens decreases effects of enoxaparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • bemiparin

              bemiparin and enoxaparin both increase anticoagulation. Avoid or Use Alternate Drug.

            • bivalirudin

              bivalirudin and enoxaparin both increase anticoagulation. Avoid or Use Alternate Drug.

            • butabarbital

              butabarbital decreases effects of enoxaparin by increasing metabolism. Avoid or Use Alternate Drug.

            • butalbital

              butalbital decreases effects of enoxaparin by increasing metabolism. Avoid or Use Alternate Drug.

            • capecitabine

              capecitabine increases effects of enoxaparin by unspecified interaction mechanism. Avoid or Use Alternate Drug. An additive risk of bleeding with enoxaparin may be seen in thrombocytopenic patients receiving antineoplastic agents like capecitabine.

            • cefamandole

              cefamandole increases effects of enoxaparin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • cefazolin

              cefazolin increases effects of enoxaparin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • cefdinir

              cefdinir increases effects of enoxaparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity.

            • cefditoren

              cefditoren will increase the level or effect of enoxaparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

            • cefotetan

              cefotetan increases effects of enoxaparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity.

            • cefoxitin

              cefoxitin will increase the level or effect of enoxaparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

            • cefpodoxime

              cefpodoxime will increase the level or effect of enoxaparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

            • ceftriaxone

              ceftriaxone increases effects of enoxaparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity.

            • cefuroxime

              cefuroxime will increase the level or effect of enoxaparin by anticoagulation. Avoid or Use Alternate Drug. cephalosporins may decrease prothrombin activity

            • cilostazol

              enoxaparin, cilostazol. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • clarithromycin

              clarithromycin increases effects of enoxaparin by decreasing metabolism. Avoid or Use Alternate Drug.

            • conjugated estrogens

              conjugated estrogens decreases effects of enoxaparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • dabigatran

              dabigatran and enoxaparin both increase anticoagulation. Avoid or Use Alternate Drug. Caution is advised, both drugs have the potential to cause bleeding. Concomitant use may increase risk of bleeding.

            • dalteparin

              dalteparin and enoxaparin both increase anticoagulation. Avoid or Use Alternate Drug.

            • dipyridamole

              enoxaparin, dipyridamole. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • edoxaban

              edoxaban, enoxaparin. Either increases toxicity of the other by anticoagulation. Avoid or Use Alternate Drug. Both drugs have the potential to cause bleeding, monitor closely. Promptly evaluate any signs or symptoms of blood loss. Long-term concomitant treatment with edoxaban and other anticoagulants is not recommended. Short-term coadministration may be needed for patients transitioning to or from edoxaban.

            • eptifibatide

              enoxaparin, eptifibatide. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • erythromycin base

              erythromycin base increases effects of enoxaparin by decreasing metabolism. Avoid or Use Alternate Drug.

            • erythromycin ethylsuccinate

              erythromycin ethylsuccinate increases effects of enoxaparin by decreasing metabolism. Avoid or Use Alternate Drug.

            • erythromycin lactobionate

              erythromycin lactobionate increases effects of enoxaparin by decreasing metabolism. Avoid or Use Alternate Drug.

            • erythromycin stearate

              erythromycin stearate increases effects of enoxaparin by decreasing metabolism. Avoid or Use Alternate Drug.

            • estradiol

              estradiol decreases effects of enoxaparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • estrogens conjugated synthetic

              estrogens conjugated synthetic decreases effects of enoxaparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • estropipate

              estropipate decreases effects of enoxaparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • ethinylestradiol

              ethinylestradiol decreases effects of enoxaparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • Factor X, human

              enoxaparin will decrease the level or effect of Factor X, human by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Based on the mechanism of action, Factor X is likely to be counteracted by direct and indirect Factor Xa inhibitors.

            • fondaparinux

              enoxaparin and fondaparinux both increase anticoagulation. Avoid or Use Alternate Drug.

            • heparin

              enoxaparin and heparin both increase anticoagulation. Avoid or Use Alternate Drug.

            • levonorgestrel intrauterine

              levonorgestrel intrauterine, enoxaparin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.

            • levonorgestrel oral

              levonorgestrel oral, enoxaparin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.

            • liothyronine

              liothyronine increases effects of enoxaparin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • mestranol

              mestranol decreases effects of enoxaparin by pharmacodynamic antagonism. Contraindicated. Risk of thromboembolic disorders.

            • pentobarbital

              pentobarbital decreases effects of enoxaparin by increasing metabolism. Avoid or Use Alternate Drug.

            • phenindione

              enoxaparin and phenindione both increase anticoagulation. Avoid or Use Alternate Drug.

            • phenobarbital

              phenobarbital decreases effects of enoxaparin by increasing metabolism. Avoid or Use Alternate Drug.

            • piperacillin

              piperacillin increases effects of enoxaparin by anticoagulation. Avoid or Use Alternate Drug. Piperacillin can inhibit platelet aggregation.

            • primidone

              primidone decreases effects of enoxaparin by increasing metabolism. Avoid or Use Alternate Drug.

            • protamine

              enoxaparin and protamine both increase anticoagulation. Avoid or Use Alternate Drug.

            • quinine

              quinine increases effects of enoxaparin by unknown mechanism. Avoid or Use Alternate Drug.

            • roxithromycin

              roxithromycin increases effects of enoxaparin by decreasing metabolism. Avoid or Use Alternate Drug.

            • secobarbital

              secobarbital decreases effects of enoxaparin by increasing metabolism. Avoid or Use Alternate Drug.

            • sulfadiazine

              sulfadiazine increases effects of enoxaparin by decreasing metabolism. Avoid or Use Alternate Drug.

              sulfadiazine increases effects of enoxaparin by plasma protein binding competition. Avoid or Use Alternate Drug.

            • sulfamethoxazole

              sulfamethoxazole increases effects of enoxaparin by decreasing metabolism. Avoid or Use Alternate Drug.

              sulfamethoxazole increases effects of enoxaparin by plasma protein binding competition. Avoid or Use Alternate Drug.

            • sulfisoxazole

              sulfisoxazole increases effects of enoxaparin by decreasing metabolism. Avoid or Use Alternate Drug.

              sulfisoxazole increases effects of enoxaparin by plasma protein binding competition. Avoid or Use Alternate Drug.

            • thyroid desiccated

              thyroid desiccated increases effects of enoxaparin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • tibolone

              tibolone increases effects of enoxaparin by pharmacodynamic synergism. Avoid or Use Alternate Drug.

            • ticlopidine

              enoxaparin, ticlopidine. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • tirofiban

              enoxaparin, tirofiban. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Enhanced risk of hemorrhage.

            • warfarin

              enoxaparin and warfarin both increase anticoagulation. Avoid or Use Alternate Drug. Additive effects are intended when both drugs are prescribed as indicated for treatment of DVT

            • zanubrutinib

              enoxaparin, zanubrutinib. Either increases effects of the other by anticoagulation. Avoid or Use Alternate Drug.

            Monitor Closely (139)

            • acalabrutinib

              acalabrutinib increases effects of enoxaparin by anticoagulation. Use Caution/Monitor. Coadministration of acalabrutinib with antiplatelets or anticoagulants may further increase risk of hemorrhage. Monitor for signs of bleeding and consider the benefit-risk of withholding acalabrutinib for 3-7 days presurgery and postsurgery depending upon the type of surgery and the risk of bleeding.

            • aceclofenac

              enoxaparin and aceclofenac both increase anticoagulation. Modify Therapy/Monitor Closely.

            • acemetacin

              enoxaparin and acemetacin both increase anticoagulation. Modify Therapy/Monitor Closely.

            • agrimony

              enoxaparin and agrimony both increase anticoagulation. Modify Therapy/Monitor Closely.

            • alfalfa

              enoxaparin and alfalfa both increase anticoagulation. Modify Therapy/Monitor Closely.

            • alteplase

              enoxaparin and alteplase both increase anticoagulation. Modify Therapy/Monitor Closely.

            • American ginseng

              enoxaparin and American ginseng both increase anticoagulation. Modify Therapy/Monitor Closely.

            • anamu

              enoxaparin and anamu both increase anticoagulation. Use Caution/Monitor.

            • aspirin

              enoxaparin and aspirin both increase anticoagulation. Use Caution/Monitor. Additive effects are intended when both drugs are prescribed as indicated for unstable angina, non-Q-wave MI, and STEMI

              aspirin, enoxaparin. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. The need for simultaneous use of low-dose aspirin and anticoagulant or antiplatelet agents are common for patients with cardiovascular disease; monitor closely.

            • aspirin rectal

              enoxaparin and aspirin rectal both increase anticoagulation. Modify Therapy/Monitor Closely.

            • aspirin/citric acid/sodium bicarbonate

              aspirin/citric acid/sodium bicarbonate, enoxaparin. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. The need for simultaneous use of low-dose aspirin and anticoagulant or antiplatelet agents are common for patients with cardiovascular disease; monitor closely.

              enoxaparin and aspirin/citric acid/sodium bicarbonate both increase anticoagulation. Use Caution/Monitor. Additive effects are intended when both drugs are prescribed as indicated for unstable angina, non-Q-wave MI, and STEMI

            • azapropazone

              azapropazone increases effects of enoxaparin by plasma protein binding competition. Use Caution/Monitor.

            • azathioprine

              azathioprine decreases effects of enoxaparin by unknown mechanism. Use Caution/Monitor.

            • azficel-T

              azficel-T, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Coadministration with anticoagulants or antiplatelets may increase bruising or bleeding at biopsy and/or injection sites; concomitant use not recommended. Decisions regarding continued use or cessation of anticoagulants or antiplatelets should be made by a physician.

            • azilsartan

              enoxaparin increases toxicity of azilsartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • benazepril

              enoxaparin increases toxicity of benazepril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • betrixaban

              enoxaparin, betrixaban. Either increases levels of the other by anticoagulation. Use Caution/Monitor.

            • budesonide

              budesonide, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • candesartan

              enoxaparin increases toxicity of candesartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • caplacizumab

              caplacizumab, enoxaparin. Either increases effects of the other by anticoagulation. Use Caution/Monitor.

            • captopril

              enoxaparin increases toxicity of captopril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • carbamazepine

              carbamazepine decreases levels of enoxaparin by increasing metabolism. Use Caution/Monitor.

            • celecoxib

              enoxaparin and celecoxib both increase anticoagulation. Modify Therapy/Monitor Closely.

            • chitosan

              chitosan increases effects of enoxaparin by Other (see comment). Use Caution/Monitor. Comment: Chitosan can decrease GI absorption of vitamin K, enhancing anticoagulant effects.

            • choline magnesium trisalicylate

              enoxaparin and choline magnesium trisalicylate both increase anticoagulation. Modify Therapy/Monitor Closely.

            • cinnamon

              enoxaparin and cinnamon both increase anticoagulation. Modify Therapy/Monitor Closely.

            • citalopram

              citalopram increases effects of enoxaparin by pharmacodynamic synergism. Use Caution/Monitor. Combination may increase risk of bleeding.

            • clopidogrel

              enoxaparin, clopidogrel. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Enhanced risk of hemorrhage; additive effects are intended when both drugs are prescribed as indicated for ACS.

            • collagenase clostridium histolyticum

              enoxaparin increases toxicity of collagenase clostridium histolyticum by anticoagulation. Use Caution/Monitor. Collagenase clostridium histolyticum has high incidence of ecchymosis/contusion at injection site; avoid concomitant anticoagulants (except for low-dose aspirin, ie, up to 150 mg/day).

            • conjugated estrogens, vaginal

              conjugated estrogens, vaginal decreases effects of enoxaparin by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Risk of thromboembolic disorders.

            • cordyceps

              enoxaparin and cordyceps both increase anticoagulation. Modify Therapy/Monitor Closely.

            • cornsilk

              cornsilk decreases effects of enoxaparin by pharmacodynamic antagonism. Use Caution/Monitor. Cornsilk contains vitamin K; consume a consistent amount daily.

            • cortisone

              cortisone, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • cyclophosphamide

              cyclophosphamide increases effects of enoxaparin by unknown mechanism. Use Caution/Monitor. Due to potential thrombocytopenic effects of cyclophosphamide, an additive risk of bleeding may be seen in patients receiving concomitant anticoagulants.

            • danshen

              enoxaparin and danshen both increase anticoagulation. Use Caution/Monitor.

            • deferasirox

              deferasirox, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Gastric ulceration and GI bleeding have been reported in patients taking deferasirox, use caution when coadministering with other drugs known to increase the risk of peptic ulcers or gastric hemorrhage including anticoagulants.

            • deflazacort

              deflazacort, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • devil's claw

              enoxaparin and devil's claw both increase anticoagulation. Use Caution/Monitor.

            • dexamethasone

              dexamethasone, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • diclofenac

              enoxaparin and diclofenac both increase anticoagulation. Modify Therapy/Monitor Closely.

            • diflunisal

              enoxaparin and diflunisal both increase anticoagulation. Modify Therapy/Monitor Closely.

              diflunisal increases effects of enoxaparin by plasma protein binding competition. Use Caution/Monitor.

            • dong quai

              enoxaparin and dong quai both increase anticoagulation. Modify Therapy/Monitor Closely.

            • enalapril

              enoxaparin increases toxicity of enalapril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • epoprostenol

              enoxaparin and epoprostenol both increase anticoagulation. Modify Therapy/Monitor Closely.

            • eprosartan

              enoxaparin increases toxicity of eprosartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • ethanol

              ethanol increases effects of enoxaparin by unknown mechanism. Use Caution/Monitor. Acute EtOH intoxication.

            • ethotoin

              enoxaparin increases levels of ethotoin by unknown mechanism. Use Caution/Monitor.

              ethotoin, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Hydantoin anticonvulsants increase anticoagulant effects at first, then decrease those effects with continued use (2+ wks). There are multiple mechanisms involved, including enzyme induction, plasma protein binding site competition, and additive effects on prothrombin time.

            • etodolac

              enoxaparin and etodolac both increase anticoagulation. Modify Therapy/Monitor Closely.

            • fenbufen

              enoxaparin and fenbufen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • fennel

              enoxaparin and fennel both increase anticoagulation. Modify Therapy/Monitor Closely.

            • fenoprofen

              enoxaparin and fenoprofen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • feverfew

              enoxaparin and feverfew both increase anticoagulation. Modify Therapy/Monitor Closely.

            • fish oil

              fish oil, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Patients taking fish oil and an anticoagulant or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding. .

            • fish oil triglycerides

              fish oil triglycerides will increase the level or effect of enoxaparin by anticoagulation. Use Caution/Monitor. Prolonged bleeding reported in patients taking antiplatelet agents or anticoagulants and oral omega-3 fatty acids. Periodically monitor bleeding time in patients receiving fish oil triglycerides and concomitant antiplatelet agents or anticoagulants.

            • fludrocortisone

              fludrocortisone, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • fluorouracil

              fluorouracil increases effects of enoxaparin by unspecified interaction mechanism. Use Caution/Monitor. Due to the thrombocytopenic effects of fluorouracil, an additive risk of bleeding may be seen in patients receiving concomitant anticoagulants.

            • flurbiprofen

              enoxaparin and flurbiprofen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • forskolin

              enoxaparin and forskolin both increase anticoagulation. Modify Therapy/Monitor Closely.

            • fosinopril

              enoxaparin increases toxicity of fosinopril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • fosphenytoin

              enoxaparin increases levels of fosphenytoin by unknown mechanism. Use Caution/Monitor.

              fosphenytoin, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Hydantoin anticonvulsants increase anticoagulant effects at first, then decrease those effects with continued use (2+ wks). There are multiple mechanisms involved, including enzyme induction, plasma protein binding site competition, and additive effects on prothrombin time.

            • garlic

              enoxaparin and garlic both increase anticoagulation. Modify Therapy/Monitor Closely.

            • gemcitabine

              gemcitabine increases effects of enoxaparin by unspecified interaction mechanism. Use Caution/Monitor. Due to the thrombocytopenic effects of gemcitabine, an additive risk of bleeding may be seen in patients receiving concomitant anticoagulants.

            • ginger

              enoxaparin and ginger both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ginkgo biloba

              enoxaparin and ginkgo biloba both increase anticoagulation. Modify Therapy/Monitor Closely.

            • glucagon intranasal

              glucagon intranasal increases effects of enoxaparin by unknown mechanism. Use Caution/Monitor.

            • green tea

              green tea, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Combination may increase risk of bleeding, caution is advised.

            • hemin

              enoxaparin, hemin. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Hemin degradation product (ie, hematin) may produce coagulopathy (eg, thrombocytopenia, platelet degranulation) and cause mild anticoagulant effects.

            • horse chestnut seed

              enoxaparin and horse chestnut seed both increase anticoagulation. Modify Therapy/Monitor Closely.

            • hydrocortisone

              hydrocortisone, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • ibrutinib

              ibrutinib will increase the level or effect of enoxaparin by anticoagulation. Use Caution/Monitor. Ibrutinib may increase the risk of hemorrhage in patients receiving antiplatelet or anticoagulant therapies and monitor for signs of bleeding.

            • ibuprofen

              enoxaparin and ibuprofen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ibuprofen IV

              enoxaparin and ibuprofen IV both increase anticoagulation. Modify Therapy/Monitor Closely.

            • icosapent

              icosapent, enoxaparin. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Icosapent may prolong bleeding time; monitor periodically if coadministered with other drugs that affect bleeding.

            • imatinib

              imatinib, enoxaparin. Either increases toxicity of the other by Other (see comment). Modify Therapy/Monitor Closely. Comment: Imatinib may cause thrombocytopenia; bleeding risk increased when imatinib is coadministered with anticoagulants, NSAIDs, platelet inhibitors, and thrombolytic agents; patients requiring anticoagulation while on imatinib should receive LMWH or unfractionated heparin instead of warfarin because of multiple interaction mechanisms of imatinib with warfarin.

            • indomethacin

              enoxaparin and indomethacin both increase anticoagulation. Modify Therapy/Monitor Closely.

            • iodine (radioactive)

              iodine (radioactive) decreases effects of enoxaparin by pharmacodynamic antagonism. Use Caution/Monitor.

            • irbesartan

              enoxaparin increases toxicity of irbesartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • ketoprofen

              enoxaparin and ketoprofen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ketorolac

              enoxaparin and ketorolac both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ketorolac intranasal

              enoxaparin and ketorolac intranasal both increase anticoagulation. Modify Therapy/Monitor Closely.

            • lisinopril

              enoxaparin increases toxicity of lisinopril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • lofepramine

              lofepramine increases levels of enoxaparin by decreasing metabolism. Use Caution/Monitor.

            • lornoxicam

              enoxaparin and lornoxicam both increase anticoagulation. Modify Therapy/Monitor Closely.

            • losartan

              enoxaparin increases toxicity of losartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • meclofenamate

              enoxaparin and meclofenamate both increase anticoagulation. Modify Therapy/Monitor Closely.

            • mefenamic acid

              enoxaparin and mefenamic acid both increase anticoagulation. Modify Therapy/Monitor Closely.

            • melatonin

              melatonin increases effects of enoxaparin by anticoagulation. Use Caution/Monitor. Melatonin may decrease prothrombin time.

            • meloxicam

              enoxaparin and meloxicam both increase anticoagulation. Modify Therapy/Monitor Closely.

            • methimazole

              methimazole decreases effects of enoxaparin by pharmacodynamic antagonism. Use Caution/Monitor.

            • methylprednisolone

              methylprednisolone, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • mistletoe

              enoxaparin increases and mistletoe decreases anticoagulation. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.

            • moexipril

              enoxaparin increases toxicity of moexipril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • nabumetone

              enoxaparin and nabumetone both increase anticoagulation. Modify Therapy/Monitor Closely.

            • naproxen

              enoxaparin and naproxen both increase anticoagulation. Modify Therapy/Monitor Closely.

            • nettle

              enoxaparin increases and nettle decreases anticoagulation. Effect of interaction is not clear, use caution. Modify Therapy/Monitor Closely.

            • nintedanib

              nintedanib increases effects of enoxaparin by anticoagulation. Use Caution/Monitor. Nintedanib is a VEGFR inhibitor, and may increase the risk of bleeding; monitor patients on full anticoagulation therapy; monitor closely for bleeding and adjust therapy as needed .

            • olmesartan

              enoxaparin increases toxicity of olmesartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • omega 3 carboxylic acids

              omega 3 carboxylic acids, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Patients taking omega-3 acids and an anticoagulant or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding.

            • omega 3 fatty acids

              omega 3 fatty acids, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Patients taking omega-3-fatty acids and an anticoagulant or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding. .

            • oxaprozin

              enoxaparin and oxaprozin both increase anticoagulation. Modify Therapy/Monitor Closely.

            • panax ginseng

              enoxaparin and panax ginseng both increase anticoagulation. Modify Therapy/Monitor Closely.

            • parecoxib

              enoxaparin and parecoxib both increase anticoagulation. Modify Therapy/Monitor Closely.

            • pau d'arco

              enoxaparin and pau d'arco both increase anticoagulation. Modify Therapy/Monitor Closely.

            • pegaspargase

              pegaspargase increases effects of enoxaparin by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of bleeding events.

            • perindopril

              enoxaparin increases toxicity of perindopril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • phenytoin

              enoxaparin increases levels of phenytoin by unknown mechanism. Use Caution/Monitor.

              phenytoin, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Hydantoin anticonvulsants increase anticoagulant effects at first, then decrease those effects with continued use (2+ wks). There are multiple mechanisms involved, including enzyme induction, plasma protein binding site competition, and additive effects on prothrombin time.

            • phytoestrogens

              enoxaparin and phytoestrogens both increase anticoagulation. Modify Therapy/Monitor Closely.

            • piroxicam

              enoxaparin and piroxicam both increase anticoagulation. Modify Therapy/Monitor Closely.

            • porfimer

              enoxaparin decreases effects of porfimer by pharmacodynamic antagonism. Use Caution/Monitor.

            • prasugrel

              enoxaparin, prasugrel. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Enhanced risk of hemorrhage.

            • prednisolone

              prednisolone, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • prednisone

              prednisone, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • propafenone

              propafenone increases effects of enoxaparin by decreasing metabolism. Use Caution/Monitor.

            • propylthiouracil

              propylthiouracil decreases effects of enoxaparin by pharmacodynamic antagonism. Use Caution/Monitor.

            • quinapril

              enoxaparin increases toxicity of quinapril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • ramipril

              enoxaparin increases toxicity of ramipril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • reishi

              enoxaparin and reishi both increase anticoagulation. Modify Therapy/Monitor Closely.

            • reteplase

              enoxaparin and reteplase both increase anticoagulation. Modify Therapy/Monitor Closely.

            • rifabutin

              rifabutin decreases levels of enoxaparin by increasing metabolism. Use Caution/Monitor.

            • rivaroxaban

              rivaroxaban, enoxaparin. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Avoid concurrent use of rivaroxaban with other anticoagulants due to increased bleeding risk other than during therapeutic transition periods where patients should be observed closely. Monitor for signs/symptoms of blood loss.

            • sacubitril/valsartan

              enoxaparin increases toxicity of sacubitril/valsartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • salicylates (non-asa)

              enoxaparin and salicylates (non-asa) both increase anticoagulation. Modify Therapy/Monitor Closely.

            • salsalate

              enoxaparin and salsalate both increase anticoagulation. Modify Therapy/Monitor Closely.

            • saw palmetto

              saw palmetto increases toxicity of enoxaparin by unspecified interaction mechanism. Use Caution/Monitor. May increase risk of bleeding.

            • Siberian ginseng

              enoxaparin and Siberian ginseng both increase anticoagulation. Modify Therapy/Monitor Closely.

            • sulfasalazine

              enoxaparin and sulfasalazine both increase anticoagulation. Modify Therapy/Monitor Closely.

            • sulindac

              enoxaparin and sulindac both increase anticoagulation. Modify Therapy/Monitor Closely.

            • telmisartan

              enoxaparin increases toxicity of telmisartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • tenecteplase

              enoxaparin and tenecteplase both increase anticoagulation. Modify Therapy/Monitor Closely.

            • ticagrelor

              ticagrelor, enoxaparin. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Increased risk of bleeding during concomitant use of medications that increase potential for bleeding.

            • tipranavir

              tipranavir increases effects of enoxaparin by pharmacodynamic synergism. Use Caution/Monitor. Tipranavir has mild antiplatelet activity that may incr bleeding risk.

            • tolfenamic acid

              enoxaparin and tolfenamic acid both increase anticoagulation. Modify Therapy/Monitor Closely.

            • tolmetin

              enoxaparin and tolmetin both increase anticoagulation. Modify Therapy/Monitor Closely.

            • trandolapril

              enoxaparin increases toxicity of trandolapril by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • triamcinolone acetonide injectable suspension

              triamcinolone acetonide injectable suspension, enoxaparin. Other (see comment). Use Caution/Monitor. Comment: Corticosteroids may decrease anticoagulant effects by increasing blood coagulability; conversely, they may impair vascular integrity, thus increasing bleeding risk. Monitor INR closely.

            • triclofos

              triclofos increases effects of enoxaparin by unspecified interaction mechanism. Use Caution/Monitor.

            • valsartan

              enoxaparin increases toxicity of valsartan by Other (see comment). Use Caution/Monitor. Comment: Low molecular weight heparins may suppress adrenal aldosterone secretion, which can potentially cause hyperkalemia.

            • vorapaxar

              enoxaparin, vorapaxar. Either increases effects of the other by anticoagulation. Use Caution/Monitor. Coadministration of anticoagulants, antiplatelets, or other drug affecting coagulation should be monitored periodically due to potential increased risk of bleeding.

            • vortioxetine

              vortioxetine and enoxaparin both increase anticoagulation. Use Caution/Monitor.

            Minor (17)

            • acetaminophen

              acetaminophen increases effects of enoxaparin by unknown mechanism. Minor/Significance Unknown.

            • acetaminophen IV

              acetaminophen IV increases effects of enoxaparin by unknown mechanism. Minor/Significance Unknown.

            • acetaminophen rectal

              acetaminophen rectal increases effects of enoxaparin by unknown mechanism. Minor/Significance Unknown.

            • alprostadil intracavernous/urethral

              alprostadil intracavernous/urethral increases effects of enoxaparin by pharmacodynamic synergism. Minor/Significance Unknown.

            • ceftaroline

              ceftaroline increases effects of enoxaparin by Other (see comment). Minor/Significance Unknown. Comment: Cephalosporins with a methylthiotetrazole (MTT) side ring (eg, cefotetan, cefoperazone) are more frequently associated with hypoprothrombinemic activity.

            • chlorella

              chlorella decreases effects of enoxaparin by pharmacodynamic antagonism. Minor/Significance Unknown. Theoretical, due to vitamin K content.

            • demeclocycline

              demeclocycline increases effects of enoxaparin by pharmacodynamic synergism. Minor/Significance Unknown.

            • dexmethylphenidate

              dexmethylphenidate increases effects of enoxaparin by decreasing metabolism. Minor/Significance Unknown.

            • doxycycline

              doxycycline increases effects of enoxaparin by pharmacodynamic synergism. Minor/Significance Unknown.

            • glyburide

              glyburide increases effects of enoxaparin by unspecified interaction mechanism. Minor/Significance Unknown.

            • mineral oil

              mineral oil decreases levels of enoxaparin by inhibition of GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown.

            • minocycline

              minocycline increases effects of enoxaparin by pharmacodynamic synergism. Minor/Significance Unknown.

            • oxytetracycline

              oxytetracycline increases effects of enoxaparin by pharmacodynamic synergism. Minor/Significance Unknown.

            • quinidine

              quinidine increases effects of enoxaparin by decreasing metabolism. Minor/Significance Unknown.

            • tetracycline

              tetracycline increases effects of enoxaparin by pharmacodynamic synergism. Minor/Significance Unknown.

            • verteporfin

              enoxaparin decreases effects of verteporfin by pharmacodynamic antagonism. Minor/Significance Unknown.

            • vitamin E

              vitamin E, enoxaparin. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Vitamin E at RDA does not change INR in pts. on chronic warfarin therapy; megadoses (~10x RDA) may enhance anticoagulant effects in vitamin K deficient pts.

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            Adverse Effects

            1-10%

            Hemorrhage (1-4%)

            Elevation of serum aminotransferases (6%)

            Fever (5-8%)

            Local site reactions (2-5%)

            Thrombocytopenia (3%)

            Nausea (3%)

            Anemia (2%)

            Ecchymosis (3%)

            <1%

            Atrial fibrillation

            Heart failure

            Pulmonary edema

            Pneumonia

            Postmarketing Reports

            Reports of epidural or spinal hematoma formation when coadministered with spinal/epidural anesthesia or spinal puncture

            Local reactions at the injection site (eg, nodules, inflammation, oozing), systemic allergic reactions (eg, pruritus, urticaria, anaphylactic/anaphylactoid reactions including shock), vesiculobullous rash, rare cases of hypersensitivity cutaneous vasculitis, purpura, skin necrosis (occurring at either the injection site or distant from the injection site), thrombocytosis, and thrombocytopenia with thrombosis

            Hyperkalemia

            Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reported

            Osteoporosis following long-term therapy

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            Warnings

            Black Box Warnings

            Epidural or spinal hematomas may occur in patients anticoagulated with low-molecular-weight heparin (LMWH) or heparinoids who receive neuraxial (epidural/spinal) anesthesia or spinal puncture

            These hematomas may result in long-term or permanent paralysis

            Patients should be frequently monitored for signs and symptoms of neurologic impairment (eg, tingling, numbness, muscular weakness)

            If neurologic compromise is noted, urgent treatment is necessary

            Physicians should consider the benefits versus risk before neuraxial intervention in patients anticoagulated or to be anticoagulated for thromboprophylaxis

            Factors increasing risk of epidural or spinal hematomas

            • Indwelling epidural catheters
            • Concomitant use of other drugs that affect hemostasis (eg, NSAIDs, platelet inhibitors, other anticoagulants)
            • History of traumatic or repeated epidural or spinal punctures
            • History of spinal deformity or spinal surgery

            Appropriate timing of enoxaparin dosing in relation to catheter placement or removal

            • Optimal timing between the administration of enoxaparin and neuraxial procedures is not known
            • Placement or removal of a spinal catheter should be delayed for at least 12 hr after administration of prophylactic doses (eg, doses used for DVT prevention)
            • Longer delays (24 hr) are appropriate to consider for patients receiving higher therapeutic doses (eg, enoxaparin 1 mg/kg BID or 1.5 mg/kg qDay)
            • A post procedure dose of enoxaparin should usually be given no sooner than 4 hr after catheter removal
            • In all cases, a benefit-risk assessment should consider both the risk for thrombosis and the risk for bleeding in the context of the procedure and patient risk factors

            Contraindications

            Active major bleeding, thrombocytopenia with antiplatelet antibody in presence of enoxaparin or heparin

            History of heparin-induced thrombocytopenia (HIT) within past 100 days or in presence of circulating antibodies

            Hypersensitivity to enoxaparin, heparin, pork products, benzyl alcohol (multiple dose formulations only) or other ingredients

            Cautions

            Epidural or spinal hemorrhage and subsequent hematomas reported with the use of enoxaparin and epidural or spinal anesthesia/analgesia or spinal puncture procedures, resulting in long-term or permanent paralysis (see Black Box Warnings)

            Use with caution in patients with a bleeding diathesis, uncontrolled arterial hypertension or a history of recent gastrointestinal ulceration, diabetic retinopathy, renal dysfunction and hemorrhage

            Bleeding may occur; monitor patients with risk factors including congenital or acquired bleeding disorders, bacterial endocarditis, severe uncontrolled hypertension, hemorrhagic stroke, used shortly after brain, spinal, or ophthalmic surgery in patients treated concomitantly with platelet inhibitors or history of heparin induced thrombocytopenia, severe liver disease, diabetic retinopathy, patients undergoing invasive procedures, active ulcerative or angiodysplastic diseases, recent GI bleeding or ulceration

            To minimize risk of bleeding following PCI, achieve hemostasis, at puncture site after PCI; sheath can be removed immediately if closure device used; if manual compression used remove sheath 6 hr after last IV/SC dose of enoxaparin; additional doses not recommended until 6-8 hr after sheath removal; observe for signs of bleeding/hematoma formation

            Multidose formulation contains benzyl alcohol preservative, linked to fatal "gasping syndrome" in premature neonates

            Monitor for hyperkalemia (possibly from aldosterone suppression); mainly a concern among patients with risk factors including renal dysfunction, concomitant use of potassium sparing diuretics or potassium supplements

            Enoxaparin-induced thrombocytopenia and thrombosis reported; use extreme caution or avoid in patients with history heparin induced thrombocytopenia (HIT), especially if administered within 100 days of HIT episode; monitor platelet count closely; discontinue therapy and consider alternate treatment if platelets are <100,000/mm³ and/or thrombosis develops

            Not for long-term thrombocytopenia in patients with prosthetic heart valves

            Heparin-induced thrombocytopenia with thrombosis (HITTS) may lead to organ infarction, limb ischemia, or death; monitor thrombocytopenia of any degree closely

            Not for IM administration

            Use caution in patients with renal impairment

            Safety and efficacy not established in obese patients (>30 kg/m²)

            Risk of bleeding may increase in women <45 kg and men <57 kg

            Not for use interchangeably (unit for unit) with heparin or any LMWHs

            Use of therapy for thromboprophylaxis in pregnant women with mechanical prosthetic heart valves may result in valve thrombosis

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            Pregnancy & Lactation

            Pregnancy

            Human data from a retrospective cohort study, suggest that enoxaparin does not increase risk of major developmental abnormalities

            Pregnancy alone confers increased risk for thromboembolism that is higher for women with thromboembolic disease and certain high risk pregnancy conditions; while not adequately studied, pregnant women with mechanical prosthetic heart valves may be at even higher risk for thrombosis; pregnant women with thromboembolic disease, including those with mechanical prosthetic heart valves and those with inherited or acquired thrombophilias, have an increased risk of other maternal complications and fetal loss regardless of type of anticoagulant used

            All patients receiving anticoagulants, including pregnant women, are at risk for bleeding; pregnant women receiving drug should be carefully monitored for evidence of bleeding or excessive anticoagulation

            Hemorrhage can occur at any site and may lead to death of mother and/or fetus; pregnant women should be apprised of potential hazard to fetus and mother if therapy is administered during pregnancy

            Animal data

            • Based on animal data, drug is not predicted to increase risk of major developmental abnormalities

            Lactation

            Unknown whether therapy is excreted in human milk; in lactating rats, passage of enoxaparin or metabolites in milk is very limited; there is no information available on effect of enoxaparin or metabolites on breastfed child, or on milk production; developmental and health benefits of breastfeeding should be considered along with mother's clinical need for therapy and any potential adverse effects on breastfed child from drug or from underlying maternal condition

            Lactation: Excretion in milk unknown; not recommended

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            LMWH; antithrombotic that inhibits factor Xa by increasing inhibition rate of clotting proteases that are activated by antithrombin III

            Generally does not increase PT or PTT

            Absorption

            Bioavailability: 92%

            Onset: 3-5 hr (peak effect)

            Duration: 12 hr (40 mg)

            AUC: 14.26 hr·U/mL

            Distribution

            Vd: 4.3 L

            Metabolism

            Metabolized by liver via desulfation and/or depolymerization to lower molecular weight species

            Elimination

            Half-life: 4.5 hr (single dose based on anti-Xa activity); 7 hr (repeated dosing)

            Total body clearance: 26 mL/min

            Excretion: Urine (40%)

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            Images

            BRAND FORM. UNIT PRICE PILL IMAGE
            Lovenox subcutaneous
            -
            120 mg/0.8 mL solution
            Lovenox subcutaneous
            -
            80 mg/0.8 mL solution
            Lovenox subcutaneous
            -
            40 mg/0.4 mL solution
            Lovenox subcutaneous
            -
            30 mg/0.3 mL solution
            Lovenox subcutaneous
            -
            300 mg/3 mL vial
            Lovenox subcutaneous
            -
            100 mg/mL solution
            Lovenox subcutaneous
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            60 mg/0.6 mL solution
            Lovenox subcutaneous
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            150 mg/mL solution
            enoxaparin subcutaneous
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            30 mg/0.3 mL solution
            enoxaparin subcutaneous
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            60 mg/0.6 mL solution
            enoxaparin subcutaneous
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            100 mg/mL solution
            enoxaparin subcutaneous
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            150 mg/mL solution
            enoxaparin subcutaneous
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            40 mg/0.4 mL solution
            enoxaparin subcutaneous
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            80 mg/0.8 mL solution
            enoxaparin subcutaneous
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            120 mg/0.8 mL solution
            enoxaparin subcutaneous
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            30 mg/0.3 mL solution
            enoxaparin subcutaneous
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            80 mg/0.8 mL solution
            enoxaparin subcutaneous
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            60 mg/0.6 mL solution
            enoxaparin subcutaneous
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            60 mg/0.6 mL solution
            enoxaparin subcutaneous
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            30 mg/0.3 mL solution
            enoxaparin subcutaneous
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            40 mg/0.4 mL solution
            enoxaparin subcutaneous
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            100 mg/mL solution
            enoxaparin subcutaneous
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            80 mg/0.8 mL solution
            enoxaparin subcutaneous
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            150 mg/mL solution
            enoxaparin subcutaneous
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            120 mg/0.8 mL solution
            enoxaparin subcutaneous
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            120 mg/0.8 mL solution
            enoxaparin subcutaneous
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            100 mg/mL solution
            enoxaparin subcutaneous
            -
            80 mg/0.8 mL solution
            enoxaparin subcutaneous
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            80 mg/0.8 mL solution
            enoxaparin subcutaneous
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            60 mg/0.6 mL solution
            enoxaparin subcutaneous
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            60 mg/0.6 mL solution
            enoxaparin subcutaneous
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            40 mg/0.4 mL solution
            enoxaparin subcutaneous
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            40 mg/0.4 mL solution
            enoxaparin subcutaneous
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            30 mg/0.3 mL solution
            enoxaparin subcutaneous
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            30 mg/0.3 mL solution
            enoxaparin subcutaneous
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            30 mg/0.3 mL solution
            enoxaparin subcutaneous
            -
            100 mg/mL solution
            enoxaparin subcutaneous
            -
            40 mg/0.4 mL solution
            enoxaparin subcutaneous
            -
            300 mg/3 mL vial
            enoxaparin subcutaneous
            -
            120 mg/0.8 mL solution
            enoxaparin subcutaneous
            -
            100 mg/mL solution
            enoxaparin subcutaneous
            -
            80 mg/0.8 mL solution
            enoxaparin subcutaneous
            -
            40 mg/0.4 mL solution
            enoxaparin subcutaneous
            -
            30 mg/0.3 mL solution
            enoxaparin subcutaneous
            -
            120 mg/0.8 mL solution
            enoxaparin subcutaneous
            -
            150 mg/mL solution
            enoxaparin subcutaneous
            -
            100 mg/mL solution
            enoxaparin subcutaneous
            -
            150 mg/mL solution
            enoxaparin subcutaneous
            -
            100 mg/mL solution
            enoxaparin subcutaneous
            -
            60 mg/0.6 mL solution
            enoxaparin subcutaneous
            -
            300 mg/3 mL vial
            enoxaparin subcutaneous
            -
            100 mg/mL solution
            enoxaparin subcutaneous
            -
            80 mg/0.8 mL solution
            enoxaparin subcutaneous
            -
            120 mg/0.8 mL solution
            enoxaparin subcutaneous
            -
            60 mg/0.6 mL solution
            enoxaparin subcutaneous
            -
            40 mg/0.4 mL solution
            enoxaparin subcutaneous
            -
            60 mg/0.6 mL solution
            enoxaparin subcutaneous
            -
            300 mg/3 mL vial
            enoxaparin subcutaneous
            -
            150 mg/mL solution
            enoxaparin subcutaneous
            -
            30 mg/0.3 mL solution
            enoxaparin subcutaneous
            -
            80 mg/0.8 mL solution
            enoxaparin subcutaneous
            -
            120 mg/0.8 mL solution
            enoxaparin subcutaneous
            -
            100 mg/mL solution
            enoxaparin subcutaneous
            -
            60 mg/0.6 mL solution
            enoxaparin subcutaneous
            -
            40 mg/0.4 mL solution
            enoxaparin subcutaneous
            -
            30 mg/0.3 mL solution
            enoxaparin subcutaneous
            -
            150 mg/mL solution
            enoxaparin subcutaneous
            -
            120 mg/0.8 mL solution
            enoxaparin subcutaneous
            -
            150 mg/mL solution
            enoxaparin subcutaneous
            -
            40 mg/0.4 mL solution
            enoxaparin subcutaneous
            -
            80 mg/0.8 mL solution

            Copyright © 2010 First DataBank, Inc.

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            Patient Handout

            Patient Education
            enoxaparin subcutaneous

            ENOXAPARIN - INJECTION

            (ee-NOX-a-PAR-in)

            COMMON BRAND NAME(S): Lovenox

            WARNING: People using this medication may bleed near the spinal cord after certain spinal procedures. Bleeding in this area can cause paralysis that lasts a long time or could become permanent. Talk with your doctor about the benefits and risks before any spinal procedure. Your doctor may direct you to stop this medication for a certain amount of time before and after the procedure. Carefully follow your doctor's directions.The risk of bleeding may be higher if you have a deformed spine, or have had spinal procedures/surgery before (such as epidural catheter placement, difficult epidural/spinal puncture), or are taking other drugs that can cause bleeding/bruising (including antiplatelet drugs such as clopidogrel, "blood thinners" such as warfarin/rivaroxaban, nonsteroidal anti-inflammatory drugs-NSAIDs such as ibuprofen). Tell your doctor right away if you notice symptoms such as back pain, leg numbness/tingling/weakness, loss of control of the bowels or bladder (incontinence).

            USES: Enoxaparin is used to prevent and treat harmful blood clots. This helps to reduce the risk of a stroke or heart attack. This medication helps keep your blood flowing smoothly by lowering the activity of clotting proteins in the blood. Enoxaparin is an anticoagulant, also known as a "blood thinner." It is a type of heparin.Conditions which increase your risk of developing blood clots include certain types of surgeries (such as knee/hip replacement, abdominal), long periods of being immobile, certain types of heart attack, and a specific type of chest pain called unstable angina. For some medical conditions, enoxaparin may be used in combination with other "blood thinners."

            HOW TO USE: Read the Patient Information Leaflet if available from your pharmacist before you start using enoxaparin and each time you get a refill. If you have any questions, ask your doctor or pharmacist.This medication is given by injection under the skin as directed by your doctor, usually once or twice a day in the abdomen (at least 2 inches from your belly button). Do not inject into a muscle. The dosage and length of treatment are based on your medical condition and response to treatment. The dosage may also be based on your age and weight for some conditions. Use this medication regularly to get the most benefit from it. To help you remember, use it at the same time(s) each day.If you are using this medication at home, learn all preparation and usage instructions from your health care professional and the product package. Before using, check this product visually for particles or discoloration. If either is present, do not use the liquid. Before injecting each dose, clean the injection site with rubbing alcohol. Change the injection site each time to lessen injury under the skin. To minimize bruising, do not rub the injection site after a shot. Learn how to store and discard medical supplies safely.This medication may also be given by injection into a vein by a health care professional, as directed by your doctor.

            SIDE EFFECTS: See also Warning section.Mild irritation, pain, bruising, redness, and swelling at the injection site may occur. Fatigue or fever may also occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.This medication can cause bleeding if its effect on your blood clotting proteins is too much. Tell your doctor right away if you have any serious signs of bleeding, including: unusual pain/swelling/discomfort, unusual or prolonged bleeding, unusual or easy bruising, dark urine, black stools, severe headache, confusion, vision changes, unusual dizziness, fainting, seizures, weakness, numbness.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

            PRECAUTIONS: Before using enoxaparin, tell your doctor or pharmacist if you are allergic to it; or to heparin or pork products; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using enoxaparin, tell your doctor or pharmacist your medical history, especially of: artificial heart valve(s), kidney disease, liver disease, bleeding/blood problems (such as low platelet counts), low platelet counts after previous heparin treatment, stroke, high blood pressure, certain eye problems (such as diabetic retinopathy), certain stomach/intestinal problems (such as active or recent ulcers), recent spinal procedure or puncture, spine problems (such as spinal deformity), recent eye/brain/spinal cord surgery.Limit alcohol while taking this drug because it may increase the risk of stomach bleeding.Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).To lower the chance of getting cut, bruised, or injured, use caution with sharp objects like razors and nail cutters, and avoid activities such as contact sports.Older adults may be more sensitive to the side effects of this drug, especially bleeding.During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor. Pregnant women with artificial heart valves need close monitoring (see Notes).It is unknown if this drug passes into breast milk. Consult your doctor before breast-feeding.

            DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.A product that may interact with this drug is: mifepristone.This medication is sometimes used together with other drugs that have "blood thinning" or anti-platelet effects such as aspirin, clopidogrel, or warfarin. When these combinations are prescribed by your doctor, you will require closer monitoring to minimize your risk of bleeding. Keep all medical and laboratory appointments.Check all prescription and nonprescription medicine labels carefully since many medications contain pain relievers/fever reducers (NSAIDs such as ibuprofen, naproxen, or aspirin) which can increase the risk of bleeding/anti-platelet effect when used with enoxaparin. However, if your doctor has directed you to take low-dose aspirin for heart attack or stroke prevention (usually 81-162 milligrams a day), you should continue taking it unless your doctor instructs you otherwise. Ask your doctor or pharmacist for more details.

            OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: excessive bleeding and bruising.

            NOTES: Do not share this medication with others.Laboratory and/or medical tests (such as blood counts including platelets, checking your stool for blood) should be performed periodically to monitor your progress or check for side effects. Additional lab tests (anti-factor Xa blood levels) should be performed in certain cases, especially if you have kidney disease, are pregnant and have artificial heart valves, or to check if enoxaparin is working well for you. Consult your doctor for more details.

            MISSED DOSE: If you miss a dose, use it as soon as you remember. If it is near the time of the next dose, skip the missed dose. Use your next dose at the regular time. Do not double the dose to catch up.

            STORAGE: Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.Do not store the multiple dose vials for more than 28 days after the first use.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

            MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information about enrolling in MedicAlert, call 1-888-633-4298 (US) or 1-800-668-1507 (Canada).

            Information last revised August 2021. Copyright(c) 2021 First Databank, Inc.

            IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

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            Formulary

            FormularyPatient Discounts

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            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.