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Enoxaparin thromboprophylaxis in hospitalized obese pediatric patients
Juwon Yim1, Afrin Jahan2, Nikolay Braykov2
1Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.
Insights
Pediatric patients with severe obesity often require higher enoxaparin doses for effective thromboprophylaxis. Monitoring anti-factor Xa (anti-Xa) levels is crucial for optimizing enoxaparin therapy in this population.
Area of Science:
- Pediatric Pharmacology
- Thromboprophylaxis
- Obesity Medicine
Background:
- Enoxaparin is a key anticoagulant for preventing blood clots in children.
- Obesity can significantly alter how the body processes enoxaparin.
- Current enoxaparin dosing guidelines for pediatric thromboprophylaxis in obese children are not well-established.
Purpose of the Study:
- To determine optimal enoxaparin dosing for thromboprophylaxis in pediatric patients with obesity.
- To evaluate the relationship between obesity severity (BMI percentile and weight) and enoxaparin dose requirements.
- To assess the achievement of therapeutic anti-factor Xa (anti-Xa) levels with standard dosing.
Main Methods:
- Retrospective review of pediatric patients (≥60 kg, BMI ≥95th percentile) who received enoxaparin for thromboprophylaxis between 2013-2022.
- Analysis of anti-Xa levels in patients initially treated with enoxaparin 30 mg every 12 hours.
- Calculation of average daily enoxaparin doses needed to reach target anti-Xa levels (0.2-0.4 unit/mL), stratified by BMI percentile and weight.
Main Results:
- Of 116 patients, 53% with BMI >99th percentile and 54% over 100 kg had sub-therapeutic anti-Xa levels (<0.2 unit/mL) on initial dosing.
- Ninety-one patients achieved therapeutic anti-Xa levels (0.2-0.4 unit/mL) with an average daily dose of 66 mg.
- Higher enoxaparin doses were significantly required for patients with BMI >99th percentile (67.8 mg/day) and those >100 kg (69.1 mg/day) compared to lower weight/BMI categories.
Conclusions:
- Standard enoxaparin dosing may be insufficient for achieving therapeutic levels in pediatric patients with severe obesity.
- Consideration of increased initial enoxaparin dosing is recommended for adolescents with severe obesity.
- Regular monitoring of anti-Xa levels is essential for effective enoxaparin thromboprophylaxis in this high-risk pediatric group.
Background:
Enoxaparin is an anticoagulant used for pharmacologic thromboprophylaxis in pediatrics. Enoxaparin pharmacokinetics can be altered in the setting of obesity. Optimal enoxaparin dosing for thromboprophylaxis in children with obesity remains unclear.
Procedure:
A retrospective review was conducted of pediatric patients who weighed ≥60 kg with BMI ≥ 95th percentile, received enoxaparin for thromboprophylaxis, and had at least one appropriately drawn anti-factor Xa (anti-Xa) from 2013 to 2022. Anti-Xa levels were reviewed for patients initially treated with enoxaparin 30 mg every 12 h. The average daily enoxaparin dose required to achieve an anti-Xa of 0.2-0.4 unit/mL, which was stratified by BMI percentile and weight, was calculated.
Results:
Of 116 patients (median age 15.8 years) included for analysis, 106 patients were initially treated with enoxaparin 30 mg every 12 h. Anti-Xa levels were <0.2 unit/mL in 53% of patients with BMI > 99th percentile and 54% of patients >100 kg. Ninety-one patients had at least one anti-Xa 0.2-0.4 unit/mL with an average daily enoxaparin dosing of 66 mg. When stratified by severity of obesity, higher doses were required to attain an anti-Xa 0.2-0.4 unit/mL in patients with BMI > 99th percentile compared with those with 95th-99th percentile (67.8 ± 15.7 vs. 62 ± 5.6 mg/day, p = .01). Patients > 100 kg required significantly higher dose than those ≤100 kg (69.1 ± 15.5 vs 61.2 ± 7.3 mg/day, p = .002).
Conclusions:
Increased initial dosing and/or anti-Xa level monitoring should be considered in adolescents with severe obesity receiving enoxaparin thromboprophylaxis.
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