| VTE treatment | VTE prophylaxis* | |
| Enoxaparin | CrCl ≥30 mL/min: No adjustment CrCl <30 mL/min: Reduce to 1 mg/kg once daily | CrCl ≥30 mL/min: No adjustment CrCl <30 mL/min: Reduce to 30 mg once daily (medical or surgical patients) |
| Dalteparin | CrCl ≥30 mL/min: No adjustment CrCl <30 mL/min: Use an anticoagulant with less dependence on renal clearance¶ | CrCl ≥30 mL/min: No adjustment |
| Nadroparin (not available in the US) | CrCl ≥50 mL/min: No adjustment CrCl 30 to 50 mL/min: Reduce dose by 25 to 33% if clinically warranted CrCl <30 mL/min: Contraindicated | CrCl ≥50 mL/min: No adjustment CrCl 30 to 50 mL/min: Reduce dose by 25 to 33% if clinically warranted CrCl <30 mL/min: Reduce dose by 25 to 33% |
| Tinzaparin (not available in the US) | CrCl ≥30 mL/min: No adjustment CrCl <30 mL/min: Use with caution, although evidence suggests no accumulation with CrCl as low as 20 mL/min | CrCl ≥30 mL/min: No adjustment CrCl <30 mL/min: Use with caution, although evidence suggests no accumulation with CrCl as low as 20 mL/min |
Use of LMW heparin in patients with renal insufficiency has been associated with hyperkalemia. Refer to the UpToDate topics on the use of heparin and LMW heparin in specific clinical conditions, for infants and children, and for acute coronary syndromes and myocardial infarction (for which there are separate tables).
VTE: venous thromboembolism; CrCl: creatinine clearance as determined by Cockcroft-Gault equation (a calculator is available in UpToDate); US: United States; LMW heparin: low molecular weight heparin; DOAC: direct oral anticoagulant.
* Applies to short-term VTE prophylaxis (up to 10 days). For long-term use, periodic anti-factor Xa activity testing may be useful to rule out drug accumulation.
¶ May consider checking anti-factor Xa activity, consistent with some authorities;[2-4] however, ranges have not been established from clinical trials and no dose adjustment nomograms have been clinically validated. Other experts and a 2018 guideline from the American Society of Hematology recommend against checking anti-factor Xa activity and suggest dose adjustments based on information in the product labeling or switching to an alternative anticoagulant such as those listed above. If monitored, levels should be measured 4 to 6 hours after dosing, following at least the third or fourth dose.Δ
Δ The following represent peak (4 hours after the dose) expected on-therapy values for therapeutic dosing (for VTE) for anti-factor Xa activity, although these have not been clinically validated:[1,2]