Dosing recommendations for enoxaparin and other LMW heparin in CKD

What are the dosing recommendations for enoxaparin and other low molecular weight heparin in CKD?

Enoxaparin dose should be adjusted for the treatment of the most common thrombotic disorders in patient with CKD. For patients with stable estimated GFR less than 30 mL/min, the dose should be adjusted to 1 mg/kg per day and Xa activities should be monitored twice a week initially, then weekly after 2 weeks of treatment.

The heparin level should be drawn 4 hours after the dose and the dose should be adjusted to heparin level of 0.7 to 1.1. Unfractionated heparin should be considered the alternative of choice for patients with unstable kidney function or undergoing dialysis.

Dosage Recommendations for Anticoagulations in Chronic Kidney Disease

DRUGSNORMAL DOSAGECKD STAGE 3-5HD
Alteplase60 mg over 1 h, then 20 mg/h for 2 h100%100%
Anistreplase30 U over 2–5 min100%100%
Apixaban5 mg po bid100%50%
Aspirin81–325 mg/day100%100%
Clopidogrel75 mg/day100%100%
Dabigatran150 mg po bid100%AVOID
Dalteparin100 U/kg100%Avoid
Check anti–factor Xa activity 4 h after second dose in patients with kidney dysfunction
Dipyridamole50 mg tid100%100%
Enoxaparin1 mg/kg q12h100%50%
Fondaparinux2.5–10 mg Subq100%Avoid
Heparin75 U/kg load then 15 U/kg/h100%100%
Iloprost0.5–2.0 ng/kg/min for 5–12 h100%100%
Prasugrel10 mg100%100%
Rivaroxaban20 mg/day50%–75%Avoid
Streptokinase250,000-U load, then 100,000 U/h100%100%
Sulfinpyrazone200 mg bid100%100%
Ticlopidine250 mg bid100%100%
Tinzaparin175 U/kg100%Avoid
Tranexamic acid25 mg/kg tid–qid50%25%
Urokinase4,400-U/kg load, then 4,400 U/kg qh100%100%
Warfarin5 mg per day then adjust per INR100%50%–100%

CKD, Chronic kidney disease; HD, hemodialysis; INR, international normalized ratio; U, units.

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