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LMWH

Indications​

  • Thromboprophylaxis
  • Prevention of clotting in the extracorporeal circuit during RRT
  • Treatment of VTE, DVT or PE for:
    • Short term for new diagnosis (5 days LMWH -> dabigatran or edoxaban)
    • Long term for patients who are intolerant or have contraindications to oral anticoagulation
  • ACS with additional requirement for anticoagulation (e.g. AF, VTE) or where CrCL < 20 mL/min
  • AF when oral anticoagulation is contraindicated (off-label use)
  • Mechanical valves when oral anticoagulation is contraindicated (off-label use)
  • Superficial vein thrombosis when fondaparinux is contraindicated

Thromboprophylaxis​

Enoxaparin dosing​

Medical and surgical patients at high risk of VTE should receive enoxaparin as shown in the table below.

WeightStandard doseRenal dose
(CrCl 15 - 30)
< 50 kg20 mg OD20 mg OD
50 to 100 kg40 mg OD20 mg OD
> 100 to 150 kg40 mg BD40 mg OD
> 150 kg60 mg BD40 mg OD
info

Patient with CrCl < 15 mL/min or on RRT should be assessed individually. If VTE prophylaxis is necessary, consider enoxaparin 20 mg OD (off-label use). Notify the renal team about these patients.

info

For patients aged 16 - 17 years:

  • On adult wards: enoxaparin as per adult dosing (off-label use)
  • On paediatric wards: dalteparin 2500 - 5000 units OD

Extended thromboprophylaxis​

Major intra-abdominal cancer surgery​

Continue LMWH for 28 days postoperatively.

Elective hip/knee replacement​

If DOAC is contraindicated, continue LMWH for 28 days after hip replacement and 14 days after knee replacement.

Fragility fractures of pelvis, hip, proximal femur​

Continue LMWH for 28 days.

Lower limb immobilisation​

Consider LMWH. Consider stopping prophylaxis if lower limb immobilisation continues beyond 42 days.

Therapeutic anticoagulation​

tip

Assess suitability for DOAC before considering therapeutic LMWH

Enoxaparin​

Indicated if CrCl > 30 mL/min.

1.5 mg/kg OD​

Default treatment of VTE.

1 mg/kg BD​

  • ACS with additional requirement for anticoagulation (e.g. AF, VTE)
  • Treatment of VTE and one of the following:
    • Weight > 100 kg
    • Recurrence or extension of thrombosis despite once-daily LMWH
    • High risk of recurrence or extension (on discussion with Haematology, Cardiology or Vascular Surgery), e.g.
      • Metallic valves where warfarin is contraindicated
      • Large burden acute iliofemoral thrombosis
      • High risk PE by ESC criteria

1 mg/kg OD​

Treatment of ACS and CrCl ≤ 20 mL/min (if CrCl > 20 mL/min, first-line treatment is fondaparinux).

info

Refer to Cardiology and Cardiothoracics teams for dosing in AF and mechanical valves.

Special groups​

Obese patients​

Use actual body weight to calculate LMWH doses. Anti-Xa activity monitoring is advisable for patients weighing > 144 kg and receiving enoxaparin.

Renal impairment​

Tinzaparin is indicated if CrCl ≤ 30 mL/min or on dialysis, except in ACS (refer to section above on enoxaparin).

Tinzaparin treatment dosing in renal impairment is shown in the table below.

CrClTinzaparin dose
20 - 30 mL/min175 units/kg OD
< 20 mL/min125 units/kg OD
Anti-Xa monitoring (discuss with Haematology)

Contraindications​

Absolute​

  • Active bleeding
  • Hypersensitivity to LMWH
  • New diagnosis of HIT

Relative​

  • Hypersensitivity to heparins
  • Hepatic impairment with coagulopathy and/or varices
  • Acute bacterial endocarditis
  • Known bleeding disorder
  • Thrombocytopenia (plt < 75 for prophylaxis, plt < 50 for treatment)
  • Peptic ulcer disease and/or oesophageal varices
  • Previous cerebral haemorrhage or acute cerebral infarct
  • Severe hypertension (SBP > 200 and/or DBP > 120)
  • Baseline APTT > 31 s, INR > 1.3 or active bleeding
  • Major trauma, recent neurosurgery or eye surgery
  • Spinal or epidural anaesthesia
  • Severe renal failure
  • History of HIT
caution

Discuss with Haematology regarding relative contraindications and alternatives in the presence of absolute contraindications.

Regional anaesthesia​

Do not use regional anaesthesia until

  • ≥ 12 hours after a prophylactic dose of LMWH, or
  • ≥ 24 hours after a therapeutic dose of LMWH

Do not remove epidural catheters until

  • ≥ 12 hours after a prophylactic dose of LMWH, or
  • ≥ 24 hours after a therapeutic dose of LMWH

Wait ≥ 4 hours before giving LMWH after

  • Removal of epidural catheters
  • Insertion of spinal blocks
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