Enoxaparin Sodium 40 mg/.4mL Injection
Other active recalls for Enoxaparin Sodium (different manufacturers) — 1 · tap to view
🆔 Identity & classification
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🏷️ RxNorm drug class
This medicine belongs to the Low Molecular Weight Heparin class.
Where does this data come from?
🏭 Manufacturer & labeler
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🩺 Clinical
Enoxaparin is used to prevent and treat deep vein thrombosis (DVT; blood clots that form in the veins, typically in the legs). It is also used to prevent complications from angina (chest pain) and heart attacks. Enoxaparin is in a class of medications called low molecular weight heparins. It works by stopping the formation of substances that cause clots.
Read the full MedlinePlus article ↗- Enoxaparin has to be injected because it can't be absorbed properly when swallowed. The good news is the needle is very small, and most people get comfortable with the technique qu...
- Why do I have to give myself shots instead of taking a pill?
- The biggest thing to watch for is unusual bleeding — that includes cuts that won't stop, blood in your urine or stool, vomiting blood, or coughing up blood. Even more urgent: if yo...
- What should I watch for that means I need to call my doctor or go to the ER?
Patient education
Supplement & herbal interactions
Enoxaparin may be associated with lower levels of 1 nutrient — worth a chat with your pharmacist, not a cause for alarm.
Where does this data come from?
Ask a licensed pharmacist directly — free, answered by our team.
🧪 Inactive Ingredients / Excipients
Inactive ingredients, also called excipients, are components of the drug product other than the active ingredient. They may include fillers, dyes, coatings, preservatives, flavors, or other formulation ingredients.
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UNII 059QF0KO0R
Water is a liquid solvent that dissolves and mixes ingredients together in liquid medicines, syrups, and injections. It helps distribute the active drug evenly throughout the product.
1 inactive ingredient listed in the exact product block matched to this NDC.
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ingredient classCode="IACT" elements from the exact product block matched by this NDC. Label-section narrative from DailyMed / the openFDA label index is shown separately when available.Inactive ingredient FAQ
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💲 Pricing
A drug doesn't have one price. Each row is a different public payment system, and none is what you'd pay at the counter — that depends on your insurance. The ⓘ on each row explains what it measures.
| Price system | Per mL | Per package |
|---|---|---|
| Retail pharmacies payNADAC · weekly | $8.125 | $32.50 / 4 ml |
| Medicaid paysCMS SDUD · 12 mo | $25.83 | $103.31 / 4 ml |
| Medicare drug plans payPart D · Q2 2026 | $10.33 | $41.33 / 4 ml |
| Medicare Part B allowsASP · J1650 | $0.536 / J1650 unit | — |
Where does this data come from?
🧾 Billing & reimbursement
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🔁 Therapeutic equivalents
| Product | Labeler | Pack | NADAC/unit | TE | Status | Price vs. this |
|---|---|---|---|---|---|---|
| Lovenox 40 mg/.4mL 00075-0620-40 | Sanofi-Aventis | 10 cellos | $6.775 | AP | Availability likely | save 17% |
| Lovenox 40 mg/.4mL 00075-8014-10 | Sanofi-Aventis | 10 cellos | $6.775 | AP | Availability likely | save 17% |
| Enoxaparin Sodium 100 mg/mL 00548-5602-00 | Amphastar | 10 syringes | $8.125 | AP | Availability likely | — |
| Enoxaparin Sodium 100 mg/mL 00781-3246-64 | Sandoz | 10 syringes | $8.125 | AP | Availability likely | — |
| Enoxaparin sodium 40 mg/.4mL 00955-1004-10 | Sanofi-Aventis | 10 cellos | $8.125 | AP | Availability likely | — |
| Enoxaparin Sodium 100 mg/mL 16714-0016-10 | NorthStar | 10 syringes | $8.125 | AP | Availability likely | — |
| Enoxaparin Sodium 40 mg/.4mLthis 63323-0564-97 | Fresenius | 1 syringe | $8.125 | AP | Availability likely | — |
| Enoxaparin Sodium 100 mg/mL 68001-0458-42 | BluePoint | 10 syringes | $8.125 | AP | Availability likely | — |
| Enoxaparin Sodium 100 mg/mL 68001-0634-42 | BluePoint | 10 syringes | $8.125 | AP | Availability likely | — |
| Enoxaparin Sodium 40 mg/.4mL 70710-1758-06 | Zydus | 10 syringes | $8.125 | AP | Availability likely | — |
| Enoxaparin Sodium 100 mg/mL 71288-0433-92 | Meitheal | 10 syringes | $8.125 | AP | Availability likely | — |
| enoxaparin sodium 40 mg/.4mL 71839-0110-10 | BE | 10 syringes | $8.125 | AP | Availability likely | — |
| Enoxaparin Sodium 40 mg/.4mL 81952-0124-24 | Hepalink | 10 syringes | $8.125 | AP | Availability likely | — |
| Enoxaparin Sodium 100 mg/mL 25021-0410-70 | Sagent | 10 syringes | $9.590 | AP | Availability likely | +18% |
| Enoxaparin Sodium 40 mg/.4mL 63323-0535-98 | Fresenius | 10 cellos | $10.682 | AP | FDA listed | +31% |
| Enoxaparin Sodium 40 mg/.4mL 72603-0175-10 | NorthStar | 10 syringes | $10.682 | AP | FDA listed | +31% |
| Enoxaparin Sodium 40 mg/.4mL 11797-0758-06 | Italfarmaco | 10 syringes | — | AP | FDA listed | — |
| enoxaparin sodium 40 mg/.4mL 28955-0102-10 | Hebei | 10 syringes | — | AP | FDA listed | — |
| Enoxaparin Sodium 100 mg/mL 55154-3541-05 | Cardinal | 5 syringes | — | AP | FDA listed | — |
| Lovenox 40 mg/.4mL 55154-4028-05 | Cardinal | 5 syringes | — | AP | FDA listed | — |
| Enoxaparin Sodium 40 mg/.4mL 55154-9586-05 | Cardinal | 5 syringes | — | AP | FDA listed | — |
| Enoxaparin Sodium 40 mg/.4mL 68083-0635-10 | Gland | 10 syringes | — | AP | FDA listed | — |
| Enoxaparin Sodium 100 mg/mL 72572-0280-10 | Civica, | 10 syringes | — | AP | FDA listed | — |
Where does this data come from?
⏳ Availability & generic status
This product is an FDA-approved generic. Other versions of the same drug are listed under Therapeutic equivalents, least expensive first.
Where does this data come from?
🗺️ Medicaid utilization & spend
💊 Medicaid utilization by pack size
📊 Medicare Part D spend CMS · PART D · 2026 (Q1)
🔬 Reported adverse events (FAERS)
Top reported reactions
Age at onset
Reporter sex
Serious outcomes
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📦 Packaging — all sizes for this product
| Package NDC | Description | Per unit | Per pack | Marketing start | Status |
|---|---|---|---|---|---|
| 63323-0564-65 | 10 BLISTER PACK in 1 CARTON (63323-564-65) / 1 SYRINGE in 1 BLISTER PACK (63323-564-63) / .4 mL in 1 SYRINGE | $8.13 / mL | $32.50 | 2019-04-23 | Active |
| 63323-0564-97 You're viewing this | 10 BLISTER PACK in 1 CARTON (63323-564-97) / 1 SYRINGE in 1 BLISTER PACK (63323-564-21) / .4 mL in 1 SYRINGE | $8.13 / mL | $32.50 | 2019-04-23 | Active |
This pack effectively ties for the lowest per-mL cost of the 2 priced pack sizes ($8.13 NADAC).
In Medicaid, this is the most-dispensed pack of this product — about 71% of fills over the last four reported quarters. See all packs ↓
Pack size FAQ
What quantity is in NDC 63323-0564-97?
What NDC number is used to bill for this package of Enoxaparin Sodium 40 mg/.4mL Injection?
Prices are the latest CMS NADAC pharmacy acquisition cost per NDC; per-pack figures are per-unit × pack quantity, shown only when the pack is denominated in the same measure NADAC prices.
📄 Full prescribing information FDA SPL
🚨 Boxed Warning ▾
WARNING: SPINAL/ EPIDURAL HEMATOMAS Epidural or spinal hematomas may occur in patients who are anticoagulated with low molecular weight heparins (LMWH) or heparinoids and are receiving neuraxial anesthesia or undergoing spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients for spinal procedures.
Factors that can increase the risk of developing epidural or spinal hematomas in these patients include: • Use of indwelling epidural catheters • Concomitant use of other drugs that affect hemostasis, such as non-steroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, and other anticoagulants • A history of traumatic or repeated epidural or spinal punctures • A history of spinal deformity or spinal surgery • Optimal timing between the administration of enoxaparin sodium injection and neuraxial procedures is not known Monitor patients frequently for signs and symptoms of neurological impairment.
If neurological compromise is noted, urgent treatment is necessary. Consider the benefits and risks before neuraxial intervention in patients anticoagulated or to be anticoagulated for thromboprophylaxis [ see Warnings and Precautions ( 5.1 ) and Drug Interactions ( 7 ) ]. WARNING: SPINAL/EPIDURAL HEMATOMAS See full prescribing information for complete boxed warning.
Epidural or spinal hematomas may occur in patients who are anticoagulated with low molecular weight heparins (LMWH) or heparinoids and are receiving neuraxial anesthesia or undergoing spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients for spinal procedures.
Factors that can increase the risk of developing epidural or spinal hematomas in these patients include: • Use of indwelling epidural catheters • Concomitant use of other drugs that affect hemostasis, such as non-steroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, and other anticoagulants • A history of traumatic or repeated epidural or spinal punctures • A history of spinal deformity or spinal surgery • Optimal timing between the administration of enoxaparin sodium injection and neuraxial procedures is not known Monitor patients frequently for signs and symptoms of neurological impairment.
If neurological compromise is noted, urgent treatment is necessary. ( 5.1 , 7 )
🎯 Indications and Usage ▾
1 INDICATIONS AND USAGE Enoxaparin sodium injection is a low molecular weight heparin [LMWH] indicated for: • Prophylaxis of deep vein thrombosis (DVT) in abdominal surgery, hip replacement surgery, knee replacement surgery, or medical patients with severely restricted mobility during acute illness ( 1.1 ) • Inpatient treatment of acute DVT with or without pulmonary embolism ( 1.2 ) • Outpatient treatment of acute DVT without pulmonary embolism ( 1.2 ) • Prophylaxis of ischemic complications of unstable angina and non-Q-wave myocardial infarction [MI] ( 1.3 ) • Treatment of acute ST-segment elevation myocardial infarction [STEMI] managed medically or with subsequent percutaneous coronary intervention [PCI] ( 1.4 )
1.1Prophylaxis of Deep Vein Thrombosis Enoxaparin sodium injection is indicated for the prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE): • in patients undergoing abdominal surgery who are at risk for thromboembolic complications [ see Clinical Studies ( 14.1 ) ] • in patients undergoing hip replacement surgery, during and following hospitalization • in patients undergoing knee replacement surgery • in medical patients who are at risk for thromboembolic complications due to severely restricted mobility during acute illness
1.2Treatment of Acute Deep Vein Thrombosis Enoxaparin sodium injection is indicated for: • the inpatient treatment of acute deep vein thrombosis with or without pulmonary embolism, when administered in conjunction with warfarin sodium • the outpatient treatment of acute deep vein thrombosis without pulmonary embolism, when administered in conjunction with warfarin sodium
1.3Prophylaxis of Ischemic Complications of Unstable Angina and Non-Q-Wave Myocardial Infarction Enoxaparin sodium injection is indicated for the prophylaxis of ischemic complications of unstable angina and non-Q-wave myocardial infarction, when concurrently administered with aspirin.
1.4Treatment of Acute ST-Segment Elevation Myocardial Infarction Enoxaparin sodium injection, when administered concurrently with aspirin, has been shown to reduce the rate of the combined endpoint of recurrent myocardial infarction or death in patients with acute ST-segment elevation myocardial infarction (STEMI) receiving thrombolysis and being managed medically or with percutaneous coronary intervention (PCI).
⏱️ Dosage and Administration ▾
2 DOSAGE AND ADMINISTRATION See full prescribing information for dosing and administration information. ( 2 )
2.1Pretreatment Evaluation Evaluate all patients for a bleeding disorder before starting enoxaparin sodium injection treatment, unless treatment is urgently needed.
2.2Adult Dosage Abdominal Surgery The recommended dose of enoxaparin sodium injection is 40 mg by subcutaneous injection once a day (with the initial dose given 2 hours prior to surgery) in patients undergoing abdominal surgery who are at risk for thromboembolic complications. The usual duration of administration is 7 to 10 days [see Clinical Studies ( 14.1 )]. Hip or Knee Replacement Surgery The recommended dose of enoxaparin sodium injection is 30 mg every 12 hours administered by subcutaneous injection in patients undergoing hip or knee replacement surgery.
Administer the initial dose 12 to 24 hours after surgery, provided that hemostasis has been established. The usual duration of administration is 7 to 10 days [see Clinical Studies ( 14.2 )]. A dose of enoxaparin sodium injection of 40 mg once a day subcutaneously may be considered for hip replacement surgery for up to 3 weeks.
Administer the initial dose 12 (±3) hours prior to surgery. Medical Patients during Acute Illness The recommended dose of enoxaparin sodium injection is 40 mg once a day administered by subcutaneous injection for medical patients at risk for thromboembolic complications due to severely restricted mobility during acute illness. The usual duration of administration is 6 to 11 days [see Clinical Studies ( 14.3 )].
Treatment of Deep Vein Thrombosis with or without Pulmonary Embolism The recommended dose of enoxaparin sodium injection is 1 mg/kg every 12 hours administered subcutaneously in patients with acute deep vein thrombosis without pulmonary embolism, who can be treated at home in an outpatient setting. The recommended dose of enoxaparin sodium injection is 1 mg/kg every 12 hours administered subcutaneously or 1.5 mg/kg once a day administered subcutaneously at the same time every day for inpatient (hospital) treatment of patients with acute deep vein thrombosis with pulmonary embolism or patients with acute deep vein thrombosis without pulmonary embolism (who are not candidates for outpatient treatment).
In both outpatient and inpatient (hospital) treatments, initiate warfarin sodium therapy when appropriate (usually within 72 hours of enoxaparin sodium injection). Continue enoxaparin sodium injection for a minimum of 5 days and until a therapeutic oral anticoagulant effect has been achieved (International Normalization Ratio 2 to 3). The average duration of administration is 7 days [see Clinical Studies ( 14.4 )].
Unstable Angina and Non-Q-Wave Myocardial Infarction The recommended dose of enoxaparin sodium injection is 1 mg/kg administered subcutaneously every 12 hours in conjunction with oral aspirin therapy (100 to 325 mg once daily) in patients with unstable angina or non–Q-wave myocardial infarction. Treat with enoxaparin sodium injection for a minimum of 2 days and continue until clinical stabilization. The usual duration of treatment is 2 to 8 days [ see Warnings and Precautions ( 5.2 ) and Clinical Studies ( 14.5 ) ].
Treatment of Acute ST-Segment Elevation Myocardial Infarction The recommended dose of enoxaparin sodium injection is a single intravenous bolus of 30 mg plus a 1 mg/kg subcutaneous dose followed by 1 mg/kg administered subcutaneously every 12 hours (maximum 100 mg for the first two doses only, followed by 1 mg/kg dosing for the remaining doses) in patients with acute ST-segment elevation myocardial infarction. Reduce the dosage in patients ≥75 years of age [see Dosage and Administration ( 2.4 )] . Unless contraindicated, administer aspirin to all patients as soon as they are identified as having STEMI and continue dosing with 75 to 325 mg once daily.
When administered in conjunction with a thrombolytic (fibrin specific or non-fibrin specific), adminis…
💊 Dosage Forms and Strengths ▾
3 DOSAGE FORMS AND STRENGTHS Enoxaparin sodium injection, USP is a clear, colorless to pale-yellow sterile solution available in two concentrations. 100 mg/mL Concentration - Single-dose Prefilled Syringes 30 mg/0.3 mL, 40 mg/0.4 mL - Single-dose Graduated Prefilled Syringes 60 mg/0.6 mL, 80 mg/0.8 mL, 100 mg/mL 150 mg/mL Concentration - Single-dose Graduated Prefilled Syringes 120 mg/0.8 mL, 150 mg/mL 100 mg/mL concentration ( 3 ): • Single-dose prefilled syringes: 30 mg/0.3 mL, 40 mg/0.4 mL • Single-dose graduated prefilled syringes: 60 mg/0.6 mL, 80 mg/0.8 mL, 100 mg/mL 150 mg/mL concentration ( 3 ): • Single-dose graduated prefilled syringes: 120 mg/0.8 mL, 150 mg/mL
⛔ Contraindications ▾
4 CONTRAINDICATIONS Enoxaparin sodium injection is contraindicated in patients with: • Active major bleeding • History of immune-mediated heparin-induced thrombocytopenia (HIT) within the past 100 days or in the presence of circulating antibodies [see Warnings and Precautions ( 5.4 )] • Known hypersensitivity to enoxaparin sodium ( e.g., pruritus, urticaria, anaphylactic/anaphylactoid reactions) [ see Adverse Reactions ( 6.2 ) ] • Known hypersensitivity to heparin or pork products • Active major bleeding ( 4 ) • History of heparin-induced thrombocytopenia (HIT) within the past 100 days or in the presence of circulating antibodies ( 4 ) • Hypersensitivity to enoxaparin sodium ( 4 ) • Hypersensitivity to heparin or pork products ( 4 )
⚠️ Warnings and Cautions ▾
5 WARNINGS AND PRECAUTIONS • Increased Risk of Hemorrhage: Monitor for sign of bleeding ( 5.1 , 5.2 , 5.3 ) • Risk of Heparin-Induced Thrombocytopenia with or without Thrombosis. ( 5.4 ) • Thrombocytopenia: Monitor platelet count closely. ( 5.5 ) • Interchangeability with other heparins: Do not exchange with heparin or other LMWHs ( 5.6 ) • Increased Risk of Thrombosis in Pregnant Women with Mechanical Prosthetic Heart Valves: Women and their fetuses may be at increased risk.
Monitor more frequently and adjust dosage as needed. ( 5.7 )
5.1Increased Risk of Hemorrhage Cases of epidural or spinal hemorrhage and subsequent hematomas have been reported with the use of enoxaparin sodium injection and epidural or spinal anesthesia/analgesia or spinal puncture procedures, resulting in long-term or permanent paralysis. The risk of these events is higher with the use of post-operative indwelling epidural catheters, with the concomitant use of additional drugs affecting hemostasis such as NSAIDs, with traumatic or repeated epidural or spinal puncture, or in patients with a history of spinal surgery or spinal deformity [ see Boxed Warning , Adverse Reactions ( 6.2 ) and Drug Interactions ( 7 ) ].
To reduce the potential risk of bleeding associated with the concurrent use of enoxaparin sodium injection and epidural or spinal anesthesia/analgesia or spinal puncture, consider the pharmacokinetic profile of enoxaparin [ see Clinical Pharmacology ( 12.3 ) ]. Placement or removal of an epidural catheter or lumbar puncture is best performed when the anticoagulant effect of enoxaparin is low; however, the exact timing to reach a sufficiently low anticoagulant effect in each patient is not known. Placement or removal of a catheter should be delayed for at least 12 hours after administration of lower doses (30 mg once or twice daily or 40 mg once daily) of enoxaparin sodium injection and at least 24 hours after the administration of higher doses (0.75 mg/kg twice-daily, 1 mg/kg twice-daily, or 1.5 mg/kg once daily) of enoxaparin sodium injection.
Anti-Xa levels are still detectable at these time points, and these delays are not a guarantee that neuraxial hematoma will be avoided. Patients receiving the 0.75 mg/kg twice daily dose, or the 1 mg/kg twice-daily dose should not receive the second enoxaparin dose in the twice daily regimen to allow a longer delay before catheter placement or removal. Likewise, although a specific recommendation for timing of a subsequent enoxaparin sodium injection dose after catheter removal cannot be made, consider delaying this next dose for at least four hours, based on a benefit-risk assessment considering both the risk for thrombosis and the risk for bleeding in the context of the procedure and patient risk factors.
For patients with creatinine clearance <30 mL/minute, additional considerations are necessary because elimination of enoxaparin is more prolonged; consider doubling the timing of removal of a catheter, at least 24 hours for the lower prescribed dose of enoxaparin sodium injection (30 mg once daily) and at least 48 hours for the higher dose (1 mg/kg/day) [ see Clinical Pharmacology ( 12.3 ) ]. Should the physician decide to administer anticoagulation in the context of epidural or spinal anesthesia/analgesia or lumbar puncture, frequent monitoring must be exercised to detect any signs and symptoms of neurological impairment such as midline back pain, sensory and motor deficits (numbness or weakness in lower limbs), and bowel and/or bladder dysfunction.
Instruct patients to report immediately if they experience any of the above signs or symptoms. If signs or symptoms of spinal hematoma are suspected, initiate urgent diagnosis and treatment including consideration for spinal cord decompression even though such treatment may not prevent or reverse neurological sequelae. Use enoxaparin sodium injection with extreme caution in conditions with increased risk of hemorrhage, such as bacterial endocarditis, cong…
🤒 Adverse Reactions ▾
6 ADVERSE REACTIONS The following serious adverse reactions are also discussed in other sections of the labeling: • Spinal/epidural hematomas [ see Boxed Warning and Warnings and Precautions ( 5.1 ) ] • Increased Risk of Hemorrhage [ see Warnings and Precautions ( 5.1 ) ] • Thrombocytopenia [ see Warnings and Precautions ( 5.5 ) ] Most common adverse reactions (>1%) were bleeding, anemia, thrombocytopenia, elevation of serum aminotransferase, diarrhea, nausea, ecchymosis, fever, edema, peripheral edema, dyspnea, confusion, and injection site pain ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Fresenius Kabi USA, LLC, at 1-800-551-7176 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch
6.1Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. During clinical development for the approved indications, 15,918 patients were exposed to enoxaparin sodium. These included 1,228 for prophylaxis of deep vein thrombosis following abdominal surgery in patients at risk for thromboembolic complications, 1,368 for prophylaxis of deep vein thrombosis following hip or knee replacement surgery, 711 for prophylaxis of deep vein thrombosis in medical patients with severely restricted mobility during acute illness, 1,578 for prophylaxis of ischemic complications in unstable angina and non-Q-wave myocardial infarction, 10,176 for treatment of acute ST-elevation myocardial infarction, and 857 for treatment of deep vein thrombosis with or without pulmonary embolism.
Enoxaparin sodium doses in the clinical trials for prophylaxis of deep vein thrombosis following abdominal or hip or knee replacement surgery or in medical patients with severely restricted mobility during acute illness ranged from 40 mg subcutaneously once daily to 30 mg subcutaneously twice daily. In the clinical studies for prophylaxis of ischemic complications of unstable angina and non-Q-wave myocardial infarction doses were 1 mg/kg every 12 hours and in the clinical studies for treatment of acute ST-segment elevation myocardial infarction enoxaparin sodium doses were a 30 mg intravenous bolus followed by 1 mg/kg every 12 hours subcutaneously.
Hemorrhage The following rates of major bleeding events have been reported during clinical trials with enoxaparin sodium injection [see Tables 2 to 7 ]. Table 2 Major Bleeding Episodes following Abdominal and Colorectal Surgery* * Bleeding complications were considered major: (1) if the hemorrhage caused a significant clinical event, or (2) if accompanied by a hemoglobin decrease ≥ 2 g/dL or transfusion of 2 or more units of blood products. Retroperitoneal, intraocular, and intracranial hemorrhages were always considered major.
Dosing Regimen Indications Enoxaparin Sodium Injection 40 mg daily subcutaneously Heparin 5000 U q8h subcutaneously Abdominal Surgery n = 555 23 (4%) n = 560 16 (3%) Colorectal Surgery n = 673 28 (4%) n = 674 21 (3%) Table 3 Major Bleeding Episodes following Hip or Knee Replacement Surgery* *Bleeding complications were considered major: (1) if the hemorrhage caused a significant clinical event, or (2) if accompanied by a hemoglobin decrease ≥ 2 g/dL or transfusion of 2 or more units of blood products. Retroperitoneal and intracranial hemorrhages were always considered major.
In the knee replacement surgery trials, intraocular hemorrhages were also considered major hemorrhages. † Enoxaparin sodium injection 30 mg every 12 hours subcutaneously initiated 12 to 24 hours after surgery and continued for up to 14 days after surgery ‡ Enoxaparin sodium injection 40 mg subcutaneously once a day initiated up to 12 hours prior to surgery and continued for up to 7 days after surgery § Enoxaparin sodium injection 40 mg subcutaneously once a day for up to 21 days after discharge Indicatio…
🔄 Drug Interactions ▾
7 DRUG INTERACTIONS Whenever possible, agents which may enhance the risk of hemorrhage should be discontinued prior to initiation of enoxaparin sodium injection therapy. These agents include medications such as: anticoagulants, platelet inhibitors including acetylsalicylic acid, salicylates, NSAIDs (including ketorolac tromethamine), dipyridamole, or sulfinpyrazone. If coadministration is essential, conduct close clinical and laboratory monitoring [ see Warnings and Precautions ( 5.1 ) ].
Discontinue agents which may enhance hemorrhage risk prior to initiation of enoxaparin sodium injection or conduct close clinical and laboratory monitoring ( 2.6 , 7 )
👥 Use in Specific Populations ▾
8 USE IN SPECIFIC POPULATIONS • Severe Renal Impairment: Adjust dose for patients with creatinine clearance <30 mL/min ( 2.3 , 8.7 ) • Geriatric Patients: Monitor for increased risk of bleeding ( 8.5 ) • Low-Weight Patients: Observe for signs of bleeding ( 8.8 )
8.1Pregnancy Risk Summary Placental transfer of enoxaparin was observed in the animal studies. Human data from a retrospective cohort study, which included 693 live births, suggest that enoxaparin does not increase the risk of major developmental abnormalities (see Data ) . Based on animal data, enoxaparin sodium injection is not predicted to increase the risk of major developmental abnormalities (see Data ).
Adverse outcomes in pregnancy occur regardless of the health of the mother or the use of medications. The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
Clinical Considerations Pregnancy alone confers an increased risk for thromboembolism that is even higher for women with thromboembolic disease and certain high-risk pregnancy conditions. While not adequately studied, pregnant women with mechanical prosthetic heart valves may be at even higher risk for thrombosis [ see Warnings and Precautions ( 5.7 ) and Use in Specific Populations ( 8.6 ) ]. Pregnant women with thromboembolic disease, including those with mechanical prosthetic heart valves and those with inherited or acquired thrombophilias, have an increased risk of other maternal complications and fetal loss regardless of the type of anticoagulant used.
All patients receiving anticoagulants, including pregnant women, are at risk for bleeding. Pregnant women receiving enoxaparin sodium injection should be carefully monitored for evidence of bleeding or excessive anticoagulation. Consideration for use of a shorter acting anticoagulant should be specifically addressed as delivery approaches [ see Boxed Warning ].
Hemorrhage can occur at any site and may lead to death of mother and/or fetus. Pregnant women should be apprised of the potential hazard to the fetus and the mother if enoxaparin sodium injection is administered during pregnancy. It is not known if monitoring of anti-Factor Xa activity and dose adjustment (by weight or anti-Factor Xa activity) of enoxaparin sodium injection affect the safety and the efficacy of the drug during pregnancy.
Data • Human Data - There are no adequate and well-controlled studies in pregnant women. A retrospective study reviewed the records of 604 women who used enoxaparin sodium injection during pregnancy. A total of 624 pregnancies resulted in 693 live births.
There were 72 hemorrhagic events (11 serious) in 63 women. There were 14 cases of neonatal hemorrhage. Major congenital anomalies in live births occurred at rates (2.5%) similar to background rates.
There have been postmarketing reports of fetal death when pregnant women received enoxaparin sodium injection. Causality for these cases has not been determined. Insufficient data, the underlying disease, and the possibility of inadequate anticoagulation complicate the evaluation of these cases.
A clinical study using enoxaparin sodium injection in pregnant women with mechanical prosthetic heart valves has been conducted [ see Warnings and Precautions ( 5.7 ) ] . • Animal Data - Teratology studies have been conducted in pregnant rats and rabbits at subcutaneous doses of enoxaparin up to 15 times the recommended human dose (by comparison with 2 mg/kg as the maximum recommended daily dose). There was no evidence of teratogenic effects or fetotoxicity due to enoxaparin. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.
8.2 Lactation Risk Summary It is unknown whether enoxaparin sodium injection i…
🤰 Pregnancy ▾
8.1Pregnancy Risk Summary Placental transfer of enoxaparin was observed in the animal studies. Human data from a retrospective cohort study, which included 693 live births, suggest that enoxaparin does not increase the risk of major developmental abnormalities (see Data ) . Based on animal data, enoxaparin sodium injection is not predicted to increase the risk of major developmental abnormalities (see Data ).
Adverse outcomes in pregnancy occur regardless of the health of the mother or the use of medications. The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
Clinical Considerations Pregnancy alone confers an increased risk for thromboembolism that is even higher for women with thromboembolic disease and certain high-risk pregnancy conditions. While not adequately studied, pregnant women with mechanical prosthetic heart valves may be at even higher risk for thrombosis [ see Warnings and Precautions ( 5.7 ) and Use in Specific Populations ( 8.6 ) ]. Pregnant women with thromboembolic disease, including those with mechanical prosthetic heart valves and those with inherited or acquired thrombophilias, have an increased risk of other maternal complications and fetal loss regardless of the type of anticoagulant used.
All patients receiving anticoagulants, including pregnant women, are at risk for bleeding. Pregnant women receiving enoxaparin sodium injection should be carefully monitored for evidence of bleeding or excessive anticoagulation. Consideration for use of a shorter acting anticoagulant should be specifically addressed as delivery approaches [ see Boxed Warning ].
Hemorrhage can occur at any site and may lead to death of mother and/or fetus. Pregnant women should be apprised of the potential hazard to the fetus and the mother if enoxaparin sodium injection is administered during pregnancy. It is not known if monitoring of anti-Factor Xa activity and dose adjustment (by weight or anti-Factor Xa activity) of enoxaparin sodium injection affect the safety and the efficacy of the drug during pregnancy.
Data • Human Data - There are no adequate and well-controlled studies in pregnant women. A retrospective study reviewed the records of 604 women who used enoxaparin sodium injection during pregnancy. A total of 624 pregnancies resulted in 693 live births.
There were 72 hemorrhagic events (11 serious) in 63 women. There were 14 cases of neonatal hemorrhage. Major congenital anomalies in live births occurred at rates (2.5%) similar to background rates.
There have been postmarketing reports of fetal death when pregnant women received enoxaparin sodium injection. Causality for these cases has not been determined. Insufficient data, the underlying disease, and the possibility of inadequate anticoagulation complicate the evaluation of these cases.
A clinical study using enoxaparin sodium injection in pregnant women with mechanical prosthetic heart valves has been conducted [ see Warnings and Precautions ( 5.7 ) ] . • Animal Data - Teratology studies have been conducted in pregnant rats and rabbits at subcutaneous doses of enoxaparin up to 15 times the recommended human dose (by comparison with 2 mg/kg as the maximum recommended daily dose). There was no evidence of teratogenic effects or fetotoxicity due to enoxaparin. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.
🧒 Pediatric Use ▾
8.4Pediatric Use Safety and effectiveness of enoxaparin sodium injection in pediatric patients have not been established. Enoxaparin sodium injection is not approved for use in neonates or infants.
🧓 Geriatric Use ▾
8.5Geriatric Use Prevention of Deep Vein Thrombosis in Hip, Knee and Abdominal Surgery; Treatment of Deep Vein Thrombosis, Prevention of Ischemic Complications of Unstable Angina and Non-Q-Wave Myocardial Infarction Over 2800 patients, 65 years and older, have received enoxaparin sodium injection in clinical trials. The efficacy of enoxaparin sodium injection in the geriatric (≥65 years) was similar to that seen in younger patients (<65 years). The incidence of bleeding complications was similar between geriatric and younger patients when 30 mg every 12 hours or 40 mg once a day doses of enoxaparin sodium injection were employed.
The incidence of bleeding complications was higher in geriatric patients as compared to younger patients when enoxaparin sodium injection was administered at doses of 1.5 mg/kg once a day or 1 mg/kg every 12 hours. The risk of enoxaparin sodium injection-associated bleeding increased with age. Serious adverse events increased with age for patients receiving enoxaparin sodium injection.
Other clinical experience (including postmarketing surveillance and literature reports) has not revealed additional differences in the safety of enoxaparin sodium injection between geriatric and younger patients. Careful attention to dosing intervals and concomitant medications (especially antiplatelet medications) is advised. Enoxaparin sodium injection should be used with care in geriatric patients who may show delayed elimination of enoxaparin.
Monitoring of geriatric patients with low body weight (<45 kg) and those predisposed to decreased renal function should be considered [ see Warnings and Precautions ( 2.6 ) and Clinical Pharmacology ( 12.3 ) ]. Treatment of Acute ST-Segment Elevation Myocardial Infarction In the clinical study for treatment of acute ST-segment elevation myocardial infarction, there was no evidence of difference in efficacy between patients ≥75 years of age (n = 1241) and patients less than 75 years of age (n = 9015). Patients ≥75 years of age did not receive a 30 mg intravenous bolus prior to the normal dosage regimen and had their subcutaneous dose adjusted to 0.75 mg/kg every 12 hours [ see Dosage and Administration ( 2.4 ) ].
The incidence of bleeding complications was higher in patients ≥65 years of age as compared to younger patients (<65 years).
🆘 Overdosage ▾
10 OVERDOSAGE Accidental overdosage following administration of enoxaparin sodium injection may lead to hemorrhagic complications. Injected enoxaparin sodium injection may be largely neutralized by the slow intravenous injection of protamine sulfate (1% solution). The dose of protamine sulfate should be equal to the dose of enoxaparin sodium injection injected: 1 mg protamine sulfate should be administered to neutralize 1 mg enoxaparin sodium injection if enoxaparin sodium was administered in the previous 8 hours.
An infusion of 0.5 mg protamine per 1 mg of enoxaparin sodium may be administered if enoxaparin sodium was administered greater than 8 hours previous to the protamine administration, or if it has been determined that a second dose of protamine is required. The second infusion of 0.5 mg protamine sulfate per 1 mg of enoxaparin sodium injection may be administered if the aPTT measured 2 to 4 hours after the first infusion remains prolonged. If at least 12 hours have elapsed since the last enoxaparin sodium injection, protamine administration may not be required; however, even with higher doses of protamine, the aPTT may remain more prolonged than following administration of heparin.
In all cases, the anti-Factor Xa activity is never completely neutralized (maximum about 60%). Particular care should be taken to avoid overdosage with protamine sulfate. Administration of protamine sulfate can cause severe hypotensive and anaphylactoid reactions.
Because fatal reactions, often resembling anaphylaxis, have been reported with protamine sulfate, it should be given only when resuscitation techniques and treatment of anaphylactic shock are readily available. For additional information consult the labeling of protamine sulfate injection products.
🧬 Clinical Pharmacology ▾
12 CLINICAL PHARMACOLOGY
12.1Mechanism of Action Enoxaparin is a low molecular weight heparin which has antithrombotic properties.
12.2Pharmacodynamics In humans, enoxaparin given at a dose of 1.5 mg/kg subcutaneously is characterized by a higher ratio of anti-Factor Xa to anti-Factor IIa activity (mean ± SD, 14.0 ± 3.1) (based on areas under anti-Factor activity versus time curves) compared to the ratios observed for heparin (mean ± SD, 1.22 ± 0.13). Increases of up to 1.8 times the control values were seen in the thrombin time (TT) and the activated partial thromboplastin time (aPTT). Enoxaparin at a 1 mg/kg dose (100 mg/mL concentration), administered subcutaneously every 12 hours to patients in a large clinical trial resulted in aPTT values of 45 seconds or less in the majority of patients (n = 1607).
A 30 mg intravenous bolus immediately followed by a 1 mg/kg subcutaneous administration resulted in aPTT post injection values of 50 seconds. The average aPTT prolongation value on Day 1 was about 16% higher than on Day 4.
12.3Pharmacokinetics Absorption Pharmacokinetic trials were conducted using the 100 mg/mL formulation. Maximum anti-Factor Xa and anti-thrombin (anti-Factor IIa) activities occur 3 to 5 hours after subcutaneous injection of enoxaparin. Mean peak anti-Factor Xa activity was
0.16IU/mL (1.58 mcg/mL) and
0.38IU/mL (3.83 mcg/mL) after the 20 mg and the 40 mg clinically tested subcutaneous doses, respectively. Mean (n = 46) peak anti-Factor Xa activity was
1.1IU/mL at steady state in patients with unstable angina receiving 1 mg/kg subcutaneously every 12 hours for 14 days. Mean absolute bioavailability of enoxaparin, after 1.5 mg/kg given subcutaneously, based on anti-Factor Xa activity is approximately 100% in healthy subjects. A 30 mg intravenous bolus immediately followed by 1 mg/kg subcutaneously every 12 hours provided initial peak anti-Factor Xa levels of
1.16IU/mL (n=16) and average exposure corresponding to 84% of steady-state levels. Steady state is achieved on the second day of treatment. Enoxaparin pharmacokinetics appears to be linear over the recommended dosage ranges [ see Dosage and Administration ( 2 ) ].
After repeated subcutaneous administration of 40 mg once daily and 1.5 mg/kg once-daily regimens in healthy volunteers, the steady-state is reached on day 2 with an average exposure ratio about 15% higher than after a single dose. Steady state enoxaparin activity levels are well predicted by single-dose pharmacokinetics. After repeated subcutaneous administration of the 1 mg/kg twice-daily regimen, the steady state is reached from day 4 with mean exposure about 65% higher than after a single dose and mean peak and trough levels of about 1.2 and
0.52IU/mL, respectively. Based on enoxaparin sodium pharmacokinetics, this difference in steady state is expected and within the therapeutic range. Although not studied clinically, the 150 mg/mL concentration of enoxaparin sodium is projected to result in anticoagulant activities similar to those of 100 mg/mL and 200 mg/mL concentrations at the same enoxaparin dose.
When a daily 1.5 mg/kg subcutaneous injection of enoxaparin sodium was given to 25 healthy male and female subjects using a 100 mg/mL or a 200 mg/mL concentration the following pharmacokinetic profiles were obtained [see Table 13 ]. Table 13 Pharmacokinetic Parameters* After 5 Days of 1.5 mg/kg Subcutaneously Once Daily Doses of Enoxaparin Sodium Using 100 mg/mL or 200 mg/mL Concentrations * Means ± SD at Day 5 and 90% Confidence Interval (CI) of the ratio † Median (range) Concentration Anti-Xa Anti-IIa Heptest aPTT A max (IU/mL or Δ sec) 100 mg/mL 1.37 (±0.23) 0.23 (±0.05) 105 (±17) 19 (±5) 200 mg/mL 1.45 (±0.22) 0.26 (±0.05) 111 (±17) 22 (±7) 90% CI 102–110% 102–111% t max † (h) 100 mg/mL 3 (2–6) 4 (2–5) 2.5 (2–4.5) 3 (2–4.5) 200 mg/mL 3.5 (2–6) 4.5 (2.5–6) 3.3 (2–5) 3 (2–5) AUC (ss) (h*IU/mL or h * Δ sec) 100 mg/mL 14.26 (±2.93) 1.54 (±0.61) 1321 (±219) 200 mg/mL 15.43 (±2.96) 1.77 (…
🧬 Mechanism of Action ▾
12.1Mechanism of Action Enoxaparin is a low molecular weight heparin which has antithrombotic properties.
📦 How Supplied / Storage and Handling ▾
16 HOW SUPPLIED/STORAGE AND HANDLING Enoxaparin sodium injection, USP is available in two concentrations [see Tables 26 and 27 ]: Table 26 100 mg/mL Concentration * Strength represents the number of milligrams of enoxaparin sodium in Water for Injection. Enoxaparin sodium injection, USP 30 and 40 mg prefilled syringes, and 60, 80, and 100 mg graduated prefilled syringes each contain 10 mg enoxaparin sodium per 0.1 mL Water for Injection. †Approximate anti-Factor Xa activity based on reference to the W.H.O. First International Low Molecular Weight Heparin Reference Standard. ‡ Each enoxaparin sodium injection, USP prefilled syringe is for single, one-time use only and is affixed with a 27 gauge × 1/2 inch needle.
Dosage Unit / Strength * Anti-Xa Activity † Unit of Sale Syringe Label Color Each Prefilled Syringes ‡ 30 mg/0.3 mL 3000 IU NDC# 63323-559-65 10 syringes per carton Medium Blue NDC# 63323-559-63 40 mg/0.4 mL 4000 IU NDC# 63323-564-65 10 syringes per carton Yellow NDC# 63323-564-63 Graduated Prefilled Syringes ‡ 60 mg/0.6 mL 6000 IU NDC# 63323-566-65 10 syringes per carton Orange NDC# 63323-566-63 80 mg/0.8 mL 8000 IU NDC# 63323-584-65 10 syringes per carton Brown NDC# 63323-584-63 100 mg/mL 10,000 IU NDC# 63323-586-65 10 syringes per carton Black NDC# 63323-586-63 Table 27 150 mg/mL Concentration * Strength represents the number of milligrams of enoxaparin sodium in Water for Injection.
Enoxaparin sodium injection, USP 120 and 150 mg graduated prefilled syringes contain 15 mg enoxaparin sodium per 0.1 mL Water for Injection . † Approximate anti-Factor Xa activity based on reference to the W.H.O. First International Low Molecular Weight Heparin Reference Standard. ‡ Each enoxaparin sodium injection, USP graduated prefilled syringe is for single, one-time use only and is affixed with a 27 gauge × 1/2 inch needle. Dosage Unit / Strength * Anti-Xa Activity † Unit of Sale Syringe Label Color Each Graduated Prefilled Syringes ‡ 120 mg/0.8 mL 12,000 IU NDC# 63323-655-56 10 syringes per carton Purple NDC# 63323-655-31 150 mg/mL 15,000 IU NDC# 63323-589-54 10 syringes per carton Navy Blue NDC# 63323-589-31 Store at 20°C to 25°C (68°F to 77°F) [see USP Controlled Room Temperature].
Store in the original carton or packaging until ready to use. Keep out of reach of children
📋 Description ▾
11 DESCRIPTION Enoxaparin sodium injection is a sterile aqueous solution containing enoxaparin sodium, a low molecular weight heparin. The pH of the injection is 5.5 to 7.5. Enoxaparin sodium is obtained by alkaline depolymerization of heparin benzyl ester derived from porcine intestinal mucosa.
Its structure is characterized by a 2-O-sulfo-4-enepyranosuronic acid group at the non-reducing end and a 2-N,6-O-disulfo-D-glucosamine at the reducing end of the chain. About 20% (ranging between 15% and 25%) of the enoxaparin structure contains an 1,6 anhydro derivative on the reducing end of the polysaccharide chain. The drug substance is the sodium salt.
The average molecular weight is about 4500 daltons. The molecular weight distribution is: <2000 daltons ≤20% 2000 to 8000 daltons ≥68% >8000 daltons ≤18% STRUCTURAL FORMULA * X = Percent of polysaccharide chain containing 1,6 anhydro derivative on the reducing end. R X * = 15 to 25% n= 0 to 20 100 - X H n =1 to 21 Enoxaparin sodium injection 100 mg/mL concentration contains 10 mg enoxaparin sodium (approximate anti-Factor Xa activity of 1000 IU [with reference to the W.H.O.
First International Low Molecular Weight Heparin Reference Standard]) per 0.1 mL Water for Injection. Enoxaparin sodium injection 150 mg/mL concentration contains 15 mg enoxaparin sodium (approximate anti-Factor Xa activity of 1500 IU [with reference to the W.H.O. First International Low Molecular Weight Heparin Reference Standard]) per 0.1 mL Water for Injection.
The enoxaparin sodium injection, USP prefilled syringes and graduated prefilled syringes are preservative-free and intended for use only as a single-dose injection [ see Dosage and Administration ( 2 ) and How Supplied/Storage and Handling ( 16 ) ]. enoxa-struc-01.jpg enoxa-struc-02.jpg
💬 Information for Patients ▾
17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Instructions for Use). If patients have had neuraxial anesthesia or spinal puncture, and particularly, if they are taking concomitant NSAIDs, platelet inhibitors, or other anticoagulants, advise them to watch for signs and symptoms of spinal or epidural hematoma, such as tingling, numbness (especially in the lower limbs) and muscular weakness. Instruct the patient to seek immediate medical attention if any of these symptoms occur.
Inform patients: • of the instructions for injecting enoxaparin sodium injection if they continue enoxaparin sodium injection therapy after discharge from the hospital. • that it may take them longer than usual to stop bleeding. • that they may bruise and/or bleed more easily when they use enoxaparin sodium injection. • that they should report any unusual bleeding, bruising, or signs of thrombocytopenia (such as a rash of dark red spots under the skin) to their physician [ see Warnings and Precautions ( 5.1 , 5.5 ) ]. • to tell their physicians and dentists they are taking enoxaparin sodium injection and/or any other product known to affect bleeding before any surgery is scheduled and before any new drug is taken [ see Warnings and Precautions ( 5.1 , 5.3 ) ]. • to tell their physicians and dentists of all medications they are taking, including those obtained without a prescription, such as aspirin or other NSAIDs [ see Drug Interactions ( 7 ) ].
Novaplus is a registered trademark of Vizient, Inc. Manufactured for: Fresenius Kabi Lake Zurich, IL 60047 www.fresenius-kabi.com/us Made in India enoxa-img-08.jpg