Use of enoxaparin in patients with chronic renal impairment: It is not clear after 25 years of its approval

The European Medicines Agency approved enoxaparin, a low-molecular-weight heparin, in 1989. Despite the benefits seen in using enoxaparin rather than unfractionated heparin in treating vein thrombosis and pulmonary embolism, enoxaparin's relatively high degree of renal excretion raises a concern for drug accumulation and a commensurate increased bleeding risk in patients with renal impairment. These pharmacokinetic properties led to an European Medicines Agency-approved two-tiered dosing strategy with a CrCl cutoff of 30 ml/min; however, both pharmacokinetic and outcomes data seem to demonstrate that enoxaparin could be used even more effectively and safely with a multitiered enoxaparin renal dosing strategy. Lower doses should be used for populations in the 30 ml/min to 50 or 60 ml/min CrCl range and in the less than more definitively refine renal dosing guidelines beyond what is currently by the European Medicines Agency. Larger controlled trials are needed to definitively establish the role and methods of using enoxaparin for vein thrombosis and pulmonary embolism with further dose adjustments in patients with varying degrees of renal impairment