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Treatment Name: Enoxaparin (Lovenox®)

Enoxaparin (Lovenox®) is a Supportive Care Therapy to prevent or treat Blood Clots

How does enoxaparin (Lovenox®) work?
Enoxaparin is designed to help your body eliminate blood clots by blocking the action of a specific clotting factor known as factor Xa (“factor ten-A”). By blocking clotting factor Xa, your body breaks down the clot faster than it can build it. This is known as “anticoagulation treatment."

Goals of therapy:
Enoxaparin (Lovenox®) is taken to prevent or treat blood clots that are harmful to your body, for example, blood clots in the heart, lungs, or brain, or those that cause swelling or pain in the arms or legs.

Enoxaparin (Lovenox®) is available as a prescription only.

Schedule

Common doses for treatment of blood clots:

  • Enoxaparin 1 mg/kg subcutaneous (S.Q.) injection every 12 hours
  • Enoxaparin 1.5 mg/kg S.Q. injection once daily
    • In most cases, enoxaparin is given twice daily to treat blood clots, but may be given only once daily in some situations.

Common doses for prevention of blood clots (prophylaxis, or prophylactic therapy)

  • Enoxaparin 40 mg S.Q. injection once daily
  • Enoxaparin 30 mg S.Q. injection every 12 hours

Note: Individual doses may vary based upon your kidney function or your doctor's recommendation. Your doctor may choose to shorten or lengthen the amount of time you stay on therapy due to certain factors specific to your case based upon the perceived risks and benefits.

It can take a long time for your body to break down and get rid of a blood clot. Typically, patients with cancer who develop a blood clot are treated with enoxaparin for at least three months, and sometimes 6 months; however, enoxaparin therapy may be continued until the cancer is no longer present in the body or your doctor may recommend that it be given indefinitely.

Side Effects

In the prescribing label information (enoxaparin, Lovenox® package insert), the most commonly reported side effects from enoxaparin (Lovenox®) are shown here. The exact percentages of patients that will experience enoxaparin side effects is unknown because it has been used under widely varying patient populations in a variety of clinical trials:

Studies have shown that enoxaparin is unlikely to cause fetal harm and can be used in pregnant women, but only if the potential benefits outweigh the risks.

*These percentages are reported from data derived specifically from treating patients with cancer who were diagnosed with a blood clot and used enoxaparin.

Note: Mild bleeding may include bruising at the injection site. It is important to rotate injection sites to prevent excessive bruising. Acceptable injection sites include the thigh and the abdomen (generally not within 2 inches of the navel).

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Monitoring

How often is monitoring needed?
Labs (blood tests) may be checked before treatment and periodically during treatment until stable. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), or basic metabolic panel (BMP), prothrombin time (PT), activated partial thromboplastin time (aPTT), plus any others your doctor may order. Low molecular weight heparin Anti-Xa (often referred to simply as “Anti ten-a”) levels may be checked in certain situations to monitor the blood activity level of enoxaparin.

How often is imaging needed?
Imaging is checked before treatment to diagnose the presence of a blood clot. Imaging may include: computerized tomography angiography (CT angiogram or CTA) scans, ventilation/perfusion (VQ) scan, or ultrasounds of arms or legs (also known as “venous dopplers”). Typically, if a blood clot is found on any of the above imaging techniques, it is not routinely repeated after starting therapy to see if the blood clot has gone away. Other imaging such as magnetic resonance imaging (MRI) or computerized tomography (CT) scans may be checked during treatment if there is a concern for bleeding into certain organs or tissues.

How might blood test results/imaging affect treatment?
Depending upon the results, your doctor may advise to continue enoxaparin as planned, temporarily hold treatment until the side effect goes away, or switch to an alternative therapy.

The serum creatinine (Scr), obtained from the “CMP” or “BMP” above, is often used to help determine the dose of enoxaparin. Adequate kidney function is required to safely dose this medication and to avoid bleeding. If your kidneys suddenly stop working or you cannot make urine, enoxaparin may be unsafe to continue and an alternative medication may be prescribed (example: heparin).

ChemoExperts Tips

  • You may bruise more easily and it may take longer to stop bleeding from simple cuts and scrapes. It is best to avoid rubbing the injection site after an enoxaparin injection as this may increase the risk of bruising
  • When taken twice a day, try to take each of the doses as close to 12 hours apart as possible
  • Enoxaparin may need to be temporarily held before and after any surgeries or procedures, or if your platelet count is too low to reduce the risk of bleeding
  • Tell your doctor if you have a known bleeding disorder before you start treatment with enoxaparin
  • When taken at home, enoxaparin is dispensed in pre-filled syringes. In some cases, the entire contents of the syringe is NOT injected. Be sure to ask you doctor, pharmacist, or nurse for instructions if a portion of the syringe contents needs to be discarded (squirted out) before injecting
  • Talk to your doctor or pharmacist before taking any over-the-counter pain medications such as ibuprofen, naproxen, and aspirin as these medications can increase the risk of bleeding when taken with enoxaparin
  • Switching from enoxaparin therapy to oral therapy with rivaroxaban or warfarin is common. If prescribed, ask your doctor or pharmacist how to safely transition from one medication to the other
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately

Patient Assistance & Co-payment Coverage

Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for Enoxaparin (Lovenox®), we have provided links that may help.

Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for Enoxaparin (Lovenox®). Depending upon your income, they may be able to help cover the cost of:

  • Enoxaparin (Lovenox®)

For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

  • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as Enoxaparin (Lovenox®) and are the best source to help you understand drug cost.

  • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

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References

1) Enoxaparin package insert prescribing label information

Created: May 15, 2017 Updated: October 24, 2018

What is Blood Clots?

To stop bleeding when an injury occurs, platelets along with a complex system of proteins called the "coagulation cascade," are activated to start the formation of blood clots when an injury occurs.

Cancer can cause the coagulation cascade to be active even when there is no injury present. These clots most commonly form in the large veins of the arms or legs (deep vein thrombosis) and can break off and travel to the lungs (pulmonary embolism), heart (myocardial infarction), or brain (thrombotic stroke).

Medications can decrease the risk of a harmful clot from forming. When an unwanted blood clot does form, medications need to be given to stop the clot from getting bigger while your body breaks down the existing clot. These medications either slow down the activity of proteins in the coagulation cascade or decrease the amount of clotting factor proteins in the blood.

NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

What is a CBC?

A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

Common uses:
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

What is a CMP?

A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

Kidney Function:
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

Liver Function:
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

Blood sugar:
13) Serum glucose

Calcium:
14) Serum calcium