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Enoxaparin Dosing and Monitoring for Therapeutic Use – Pediatric – Inpatient [134]

Enoxaparin Dosing and Monitoring for Therapeutic Use – Pediatric – Inpatient [134] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols


Delegation Protocol Number: 134
Delegation Protocol Title:
Enoxaparin Dosing and Monitoring for Therapeutic Use – Pediatric – Inpatient
Delegation Protocol Applies To:
Any pediatric patient (< 18 years old) with an active order for treatment doses of enoxaparin
Target Patient Population:
Any pediatric patient (< 18 years old) with an active order for treatment doses of enoxaparin
Delegation Protocol Champion:
Anne Rose, PharmD - Anticoagulation Stewardship Program
Carol Diamond, MD – Department of Pediatrics - Hematology/Oncology
Delegation Protocol Reviewers:
Brian LaRowe, PharmD – Pediatrics - Pharmacy Department
Nicole Lubcke, PharmD – Pediatrics - Pharmacy Department
Jennifer Nguyen, PharmD – Pediatrics - Pharmacy Department
Anne Rose, PharmD – Anticoagulation Stewardship Program
Responsible Department:
Department of Pharmacy
Purpose Statement:
To delegate the dosing and laboratory ordering for the titration of enoxaparin from the ordering provider
to the pharmacist to achieve a defined therapeutic goal. Standardization of dosing, monitoring and
titration of enoxaparin can improve the time to a therapeutic level which can improve outcomes related to
thromboembolic and bleeding events.
Who May Carry Out This Delegation Protocol:
Inpatient clinical pharmacists licensed in the state of Wisconsin who practice in the area of pediatrics
and whom are trained in the use of this delegation protocol.
Guidelines for Implementation:
1. The protocol is initiated when the provider enters an order for enoxaparin at a treatment dose in a
pediatric patient within the American Family Children’s Hospital (AFCH) or University Of Wisconsin
Hospital (UWHC)
1.1. Enoxaparin orders for prevention of venous thromboembolism are excluded from this
protocol.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

2. Upon receipt of the order the pharmacist will complete an assessment of the patient’s age, actual
body weight and renal function to determine if the ordered enoxaparin dose is correct. Pharmacist
will also verify if the patient has any allergies.
2.1 The pharmacist will use the recommendations provided in Table 1 to determine correct
treatment dosing.
2.2 If an adjustment to the enoxaparin dose is needed, the pharmacist will discontinue the original
enoxaparin order and enter a new order for enoxaparin with the corrected dose.
2.3 Doses of enoxaparin will be rounded to the nearest whole milligram
3. After the first dose of enoxaparin has been administered, the pharmacist will order an anti-Xa level
as directed in Table 2.
3.1 Subsequent anti-Xa levels will be ordered as outlined in Table 2.
3.2 Maintenance monitoring of anti-Xa levels are outlined in Table 2.
4. The pharmacist will adjust the enoxaparin dose as outlined in Table 3 until a therapeutic anti-Xa
level has been achieved.
5. The pharmacist will also ensure appropriate maintenance monitoring for enoxaparin is completed.
5.1 Recommendations for maintenance monitoring is outlined in Table 4.
5.2 The pharmacist will order maintenance monitoring labs if not previously ordered.
Order Mode:
Medications – Protocol/Policy without Cosign
Laboratory Orders – Cosign Required – Protocol/Policy

References:
1. Andrade-Campos MM, Montes-Limon AE, Fernandez-Mosteirin N, et al. Dosing and monitoring
of enoxaparin therapy in children: experience in a tertiary care hospital. Blood Coagul
Fibrinolysis 2013; 24(2):194-8.
2. Bauman ME, Belletrutti MJ, Bajzar L, et al. Evaluation of enoxaparin dosing requirements in
infants and children: better dosing to achieve therapeutic levels. Throm Haemost.
2009;101(1):86-92.
3. Cies J, Santos L, and Chopra A. IV enoxaparin in pediatric and cardiac ICU patients. Pediatr Crit
Care Med. 2014; 15:e95-e103.
4. Chander A, Nagel K, Wiernikowski, et al. Evaluation of the use of low-molecular weight heparin
in neonates: a retrospective, single center study. Clin Appl Thromb Hemost. 2013; 19(5):488-93.
5. Duplaga BA, Rivers CW and Nutescu E. Dosing and monitoring of low-molecular-weight heparins
in special populations. Pharmacotherapy.2001; 21:218-34.
6. Fung LS, Klockau C. Effects of age and weight-based dosing of enoxaparin on anti-factor Xa
concentrations in pediatric patients. J Pediatr Pharmacol Ther. 2010;15(2):119-125.
7. Goldsmith R, Chan AK, Paes BA, et al. Feasibility and safety of enoxaparin whole milligram dosing
in premature and term neonates. J Perinatol. 2015; Jul doi:10.1038
8. Ignjatovic V, Najid S, Newall F, et al. Dosing and monitoring of enoxaparin (low molecular weight
heparin) therapy in children. Br J Haematol. 2010;149(5):734-738.
9. Monagle P, Chan AK, Goldenberg NA, et al. Antithrombotic therapy in neonates and children:
American College of Chest Physicians. Evidence-Based Clinical Practice Guidelines (9
th
Edition).
CHEST. 2012; 141:737-801.

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Collateral Documents/Tools: NA

Table 1: Treatment dosing of enoxaparin in neonatal and pediatric patients
Age Standard Dosing Renal Dosing
< 2 months 2 mg/kg every 12 hours 2 mg/kg every 24 hours
2 months – 10 years 1.5 mg/kg every 12 hours 1.5 mg/kg every 24 hours
> 10 years 1 mg/kg every 12 hours 1 mg/kg every 24 hours
*Doses will be rounded to the nearest whole milligram


Table 2: Monitoring Anti-Xa levels
Anti-Xa level monitoring
Enoxaparin dose or with any change in
enoxaparin dosing
4 hours after each dose administered until therapeutic
level is achieved.
When 1
st
therapeutic level achieved 4 hours after next enoxaparin dose to confirm therapeutic
range.
When 2nd therapeutic level achieved Repeat in 7 days
- If therapeutic < 48 hours from initiating enoxaparin,
then recheck anti-Xa level in another 48 hours. If
therapeutic then move to maintenance monitoring.
- If therapeutic > 48 hours from initiating enoxaparin, the
move to maintenance monitoring .
Maintenance monitoring 14 days
Renal insufficiency
(CRCl < 30 mL/min and not on renal
replacement therapy)
4 hours after each dose administered until therapeutic
level is achieved, then check every 48-72 hours while
patient remains hospitalized.


Table 3. Enoxaparin dose adjustments based on the Anti-Xa level
Anti-Xa Level
(units/mL)
Hold Next Dose Dosage Change Next Anti-Xa Level
< 0.35 No Increase by 25% 4 hrs after next dose
0.35 - 0.49 No Increase by 10% 4 hrs after next dose
0.50 - 1.10 No No See Table 2
1.11 - 1.50 No Decrease by 20% Before next dose
1.51 - 2.00 3 hrs Decrease by 30% Before next dose &
4 hrs after next dose
> 2.01 Until anti-Xa < 0.5
units/mL
Contact MD
Decrease by 40%
Every 12 hrs until anti-Xa < 0.5
units/mL

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Table 4. Monitoring low molecular weight heparin
Lab Prior Initial Phase Maintenance Phase
Hemoglobin/
Hematocrit
Baseline After 7 days
Every 2-4 weeks or as clinically
indicated*
Platelet Baseline
After 24 hours x 1, then
every 48 hours for 14 days
Every 2-4 weeks or as clinically
indicated*
Serum Creatinine Baseline After 7 days
Every 1-4 weeks or as clinically
indicated*
*For abnormal values may monitor more frequently


Approved By:
Inpatient Anticoagulation Committee: September 2015
UW Health Laboratory Practices Committee: October 2015
UWHC Pharmacy and Therapeutics Committee: January 2016
UWHC Medical Board: February 2016

Effective Date: February 2016

Scheduled for Review: February 2018

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org