4.1. Therapeutic indications

Inhixa is indicated in adults for:

Prophylaxis of venous thromboembolic disease in moderate and high risk surgical patients, in particular those undergoing orthopaedic or general surgery including cancer surgery.

Prophylaxis of venous thromboembolic disease in medical patients with an acute illness (such as acute heart failure, respiratory insufficiency, severe infections or rheumatic diseases) and reduced mobility at increased risk of venous thromboembolism.

Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), excluding PE likely to require thrombolytic therapy or surgery.

Extended treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of its recurrence in patients with active cancer.

Prevention of thrombus formation in extra corporeal circulation during haemodialysis.

Acute coronary syndrome:

• Treatment of unstable angina and Non ST-segment elevation myocardial infarction (NSTEMI), in combination with oral acetylsalicylic acid.

• Treatment of acute ST-segment elevation myocardial infarction (STEMI) including patients to be managed medically or with subsequent percutaneous coronary intervention (PCI).

4.2. Posology and method of administration

Posology

Prophylaxis of venous thromboembolic disease in moderate and high risk surgical patients

Individual thromboembolic risk for patients can be estimated using validated risk stratification model.

In patients at moderate risk of thromboembolism, the recommended dose of enoxaparin sodium is 2,000 IU (20 mg) once daily by subcutaneous (SC) injection. Preoperative initiation (2 hours before surgery) of enoxaparin sodium 2,000 IU (20 mg) was proven effective and safe in moderate risk surgery.

In moderate risk patients, enoxaparin sodium treatment should be maintained for a minimal period of 7‑10 days whatever the recovery status (e.g. mobility). Prophylaxis should be continued until the patient no longer has significantly reduced mobility.

In patients at high risk of thromboembolism, the recommended dose of enoxaparin sodium is 4,000 IU (40 mg) once daily given by SC injection preferably started 12 hours before surgery. If there is a need for earlier than 12 hours enoxaparin sodium preoperative prophylactic initiation (e.g. high risk patient waiting for a deferred orthopaedic surgery), the last injection should be administered no later than 12 hours prior to surgery and resumed 12 hours after surgery.

o For patients who undergo major orthopaedic surgery an extended thromboprophylaxis up to 5 weeks is recommended.

o For patients with a high venous thromboembolism (VTE) risk who undergo abdominal or pelvic surgery for cancer an extended thromboprophylaxis up to 4 weeks is recommended.

Prophylaxis of venous thromboembolism in medical patients

The recommended dose of enoxaparin sodium is 4,000 IU (40 mg) once daily by SC injection.

Treatment with enoxaparin sodium is prescribed for at least 6 to 14 days whatever the recovery status (e.g. mobility). The benefit is not established for a treatment longer than 14 days.

Treatment of DVT and PE

Enoxaparin sodium can be administered SC either as a once daily injection of 150 IU/kg (1.5 mg/kg) or as twice daily injections of 100 IU/kg (1 mg/kg).

The regimen should be selected by the physician based on an individual assessment including evaluation of the thromboembolic risk and of the risk of bleeding. The dose regimen of 150 IU/kg (1.5 mg/kg) administered once daily should be used in uncomplicated patients with low risk of VTE recurrence. The dose regimen of 100 IU/kg (1 mg/kg) administered twice daily should be used in all other patients such as those with obesity, with symptomatic PE, cancer, recurrent VTE or proximal (vena iliaca) thrombosis.

Enoxaparin sodium treatment is prescribed for an average period of 10 days. Oral anticoagulant therapy should be initiated when appropriate (see “Switch between enoxaparin sodium and oral anticoagulants” at the end of section 4.2).

In the extended treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of its recurrence in patients with active cancer, physicians should carefully assess the individual thromboembolic and bleeding risks of the patient.

The recommended dose is 100 IU/kg (1 mg/kg) administered twice daily by SC injections for 5 to 10 days, followed by a 150 IU/kg (1.5 mg/kg) once daily SC injection up to 6 months. The benefit of continuous anticoagulant therapy should be reassessed after 6 months of treatment.

Prevention of thrombus formation during haemodialysis

The recommended dose is 100 IU/kg (1 mg/kg) of enoxaparin sodium.

For patients with a high risk of haemorrhage, the dose should be reduced to 50 IU/kg (0.5 mg/kg) for double vascular access or 75 IU/kg (0.75 mg/kg) for single vascular access.

During haemodialysis, enoxaparin sodium should be introduced into the arterial line of the circuit at the beginning of the dialysis session. The effect of this dose is usually sufficient for a 4-hour session; however, if fibrin rings are found, for example after a longer than normal session, a further dose of 50 IU to 100 IU/kg (0.5 to 1 mg/kg) may be given.

No data are available in patients using enoxaparin sodium for prophylaxis or treatment and during haemodialysis sessions.

Acute coronary syndrome: treatment of unstable angina and NSTEMI and treatment of acute STEMI

For treatment of unstable angina and NSTEMI, the recommended dose of enoxaparin sodium is 100 IU/kg (1 mg/kg) every 12 hours by SC injection administered in combination with antiplatelet therapy. Treatment should be maintained for a minimum of 2 days and continued until clinical stabilization. The usual duration of treatment is 2 to 8 days.

Acetylsalicylic acid is recommended for all patients without contraindications at an initial oral loading dose of 150–300 mg (in acetylsalicylic acid-naive patients) and a maintenance dose of 75–325 mg/day long-term regardless of treatment strategy.

For treatment of acute STEMI, the recommended dose of enoxaparin sodium is a single intravenous (IV) bolus of 3,000 IU (30 mg) plus a 100 IU/kg (1 mg/kg) SC dose followed by 100 IU/kg (1 mg/kg) administered SC every 12 hours (maximum 10,000 IU (100 mg) for each of the first two SC doses). Appropriate antiplatelet therapy such as oral acetylsalicylic acid (75 mg to 325 mg once daily) should be administered concomitantly unless contraindicated. The recommended duration of treatment is 8 days or until hospital discharge, whichever comes first. When administered in conjunction with a thrombolytic (fibrin specific or non-fibrin specific), enoxaparin sodium should be given between 15 minutes before and 30 minutes after the start of fibrinolytic therapy.

o For dose in patients ≥ 75 years of age, see paragraph “Elderly”.

o For patients managed with PCI, if the last dose of enoxaparin sodium SC was given less than 8 hours before balloon inflation, no additional dosing is needed. If the last SC administration was given more than 8 hours before balloon inflation, an IV bolus of 30 IU/kg (0.3 mg/kg) enoxaparin sodium should be administered.

Special populations

Paediatric population

The safety and efficacy of enoxaparin sodium in paediatric population have not been established.

Elderly

For all indications except STEMI, no dose reduction is necessary in the elderly patients, unless kidney function is impaired (see below “renal impairment” and section 4.4).

For treatment of acute STEMI in elderly patients ≥75 years of age, an initial IV bolus must not be used. Initiate dosing with 75 IU/kg (0.75 mg/kg) SC every 12 hours (maximum 7,500 IU (75 mg) for each of the first two SC doses only, followed by 75 IU/kg (0.75 mg/kg) SC dosing for the remaining doses). For dose in elderly patients with impaired kidney function, see below “renal impairment” and section 4.4.

Hepatic impairment

Limited data are available in patients with hepatic impairment (see sections 5.1 and 5.2) and caution should be used in these patients (see section 4.4).

Renal impairment (see sections 4.4 and 5.2)

Severe renal impairment

Enoxaparin sodium is not recommended for patients with end stage renal disease (creatinine clearance <15 mL/min) due to lack of data in this population outside the prevention of thrombus formation in extra corporeal circulation during haemodialysis.

Dose table for patients with severe renal impairment (creatinine clearance [15-30] mL/min):

Indication

Dosing regimen

Prophylaxis of venous thromboembolic disease

2,000 IU (20 mg) SC once daily

Treatment of DVT and PE

100 IU/kg (1 mg/kg) body weight SC once daily

Extended treatment of DVT and PE in patients with active cancer

100 IU/kg (1 mg/kg) body weight SC once daily

Treatment of unstable angina and NSTEMI

100 IU/kg (1 mg/kg) body weight SC once daily

Treatment of acute STEMI (patients under 75)

Treatment of acute STEMI (patients over 75)

1 x 3,000 IU (30 mg) IV bolus plus 100 IU/kg (1 mg/kg) body weight SC and then 100 IU/kg (1 mg/kg) body weight SC every 24 hours

No IV initial bolus, 100 IU/kg (1 mg/kg) body weight SC and then 100 IU/kg (1 mg/kg) body weight SC every 24 hours

The recommended dose adjustments do not apply to the haemodialysis indication.

Moderate and mild renal impairment

Although no dose adjustment is recommended in patients with moderate (creatinine clearance 30‑50 mL/min) and mild (creatinine clearance 50-80 mL/min) renal impairment, careful clinical monitoring is advised.

Method of administration

Inhixa is not indicated for intramuscular use and should not be administered by this route.

For the prophylaxis of venous thrombo-embolic disease following surgery, treatment of DVT and PE, extended treatment of DVT and PE in patients with active cancer, treatment of unstable angina and NSTEMI, enoxaparin sodium should be administered by SC injection.

For acute STEMI, treatment is to be initiated with a single IV bolus injection immediately followed by a SC injection.

For the prevention of thrombus formation in the extra corporeal circulation during haemodialysis, it is administered through the arterial line of a dialysis circuit.

The disposable pre-filled syringe is ready for immediate use.

The use of a tuberculin syringe or equivalent is recommended when using ampoules or multidose vials to assure withdrawal of the appropriate volume of the medicinal product.

SC injection technique

Injection should be made preferably when the patient is lying down. Enoxaparin sodium is administered by deep SC injection.

When using pre‑filled syringes, the air bubble should not be expelled from the syringe before the injection in order to avoid the loss of the medicinal product. When the quantity of the medicinal product to be injected requires to be adjusted based on the patient's body weight, use the graduated pre-filled syringes to reach the required volume by discarding the excess before injection. Please be aware that in some cases it is not possible to achieve an exact dose due to the graduations on the syringe, and in such case the volume shall be rounded up to the nearest graduation.

The administration should be alternated between the left and right anterolateral or posterolateral abdominal wall.

The whole length of the needle should be introduced vertically into a skin fold gently held between the thumb and index finger. The skin fold should not be released until the injection is complete. After administration, the injection site should not be rubbed.

Note for the pre-filled syringes fitted with an automatic safety system: The safety system is triggered at the end of the injection (see instructions in section 6.6).

In case of self-administration, patient should be advised to follow instructions provided in the patient information leaflet included in the pack of this medicinal product.

IV (bolus) injection (for acute STEMI indication only)

For acute STEMI, treatment is to be initiated with a single IV bolus injection immediately followed by a SC injection.

For IV injection, either the multidose vial or pre-filled syringe can be used.

Enoxaparin sodium should be administered through an IV line. It should not be mixed or co-administered with other medicinal products. To avoid the possible mixture of enoxaparin sodium with other medicinal products, the IV access chosen should be flushed with a sufficient amount of sodium chloride 9 mg/ml (0.9%) or 5% glucose in water for injections prior to and following the IV bolus administration of enoxaparin sodium to clear the port of the medicinal product. Enoxaparin sodium may be safely administered with normal sodium chloride 9 mg/ml (0.9%) solution for injection or 5% glucose in water for injections.

Initial 3,000 IU (30 mg) bolus

For the initial 3,000 IU (30 mg) bolus, using an enoxaparin sodium graduated pre-filled syringe, the excessive volume has to be expelled to retain only 3,000 IU (30 mg) in the syringe. The 3,000 IU (30 mg) dose can then be directly injected into the IV line.

Additional bolus for PCI when last SC administration was given more than 8 hours before balloon inflation

For patients being managed with PCI, an additional IV bolus of 30 IU/kg (0.3 mg/kg) is to be administered if last SC administration was given more than 8 hours before balloon inflation.

In order to assure the accuracy of the small volume to be injected, it is recommended to dilute the medicinal product to 300 IU/mL (3 mg/mL).

To obtain a 300 IU/mL (3 mg/mL) solution, using a 6,000 IU (60 mg) enoxaparin sodium pre-filled syringe, it is recommended to use a 50 mL infusion bag (i.e. using either sodium chloride 9 mg/ml (0.9%) solution for injection or 5% glucose in water for injections) as follows:

Withdraw 30 mL from the infusion bag with a syringe and discard the liquid. Inject the complete contents of the 6,000 IU (60 mg) enoxaparin sodium pre-filled syringe into the 20 mL remaining in the bag. Gently mix the contents of the bag. Withdraw the required volume of diluted solution with a syringe for administration into the IV line.

After dilution is completed, the volume to be injected can be calculated using the following formula [volume of diluted solution (mL) = patient weight (kg) x 0.1] or using the table below. It is recommended to prepare the dilution immediately before use.

Volume to be injected through IV line after dilution is completed at a concentration of 300 IU (3 mg) /mL.

Weight

Required dose

30 IU/kg (0.3 mg/kg)

Volume to inject when diluted to a final concentration of 300 IU (3 mg)/mL

[kg]

IU

[mg]

[mL]

45

1,350

13.5

4.5

50

1,500

15

5

55

1,650

16.5

5.5

60

1,800

18

6

65

1,950

19.5

6.5

70

2,100

21

7

75

2,250

22.5

7.5

80

2,400

24

8

85

2,550

25.5

8.5

90

2,700

27

9

95

2,850

28.5

9.5

100

3,000

30

10

105

3,150

31.5

10.5

110

3,300

33

11

115

3,450

34.5

11.5

120

3,600

36

12

125

3,750

37.5

12.5

130

3,900

39

13

135

4,050

40.5

13.5

140

4,200

42

14

145

4,350

43.5

14.5

150

4,500

45

15

Arterial line injection

It is administered through the arterial line of a dialysis circuit for the prevention of thrombus formation in the extra corporeal circulation during haemodialysis.

Switch between enoxaparin sodium and oral anticoagulants

Switch between enoxaparin sodium and vitamin K antagonists (VKA)

Clinical monitoring and laboratory tests [prothrombin time expressed as the International Normalised Ratio (INR)] must be intensified to monitor the effect of VKA.

As there is an interval before the VKA reaches its maximum effect, enoxaparin sodium therapy should be continued at a constant dose for as long as necessary in order to maintain the INR within the desired therapeutic range for the indication in two successive tests.

For patients currently receiving a VKA, the VKA should be discontinued and the first dose of enoxaparin sodium should be given when the INR has dropped below the therapeutic range.

Switch between enoxaparin sodium and direct oral anticoagulants (DOAC)

For patients currently receiving enoxaparin sodium, discontinue enoxaparin sodium and start the DOAC 0 to 2 hours before the time that the next scheduled administration of enoxaparin sodium would be due as per DOAC label.

For patients currently receiving a DOAC, the first dose of enoxaparin sodium should be given at the time the next DOAC dose would be taken.

Administration in spinal/epidural anaesthesia or lumbar puncture

Should the physician decide to administer anticoagulation in the context of epidural or spinal anaesthesia/analgesia or lumbar puncture, careful neurological monitoring is recommended due to the risk of neuraxial haematomas (see section 4.4).

• At doses used for prophylaxis

A puncture-free interval of at least 12 hours shall be kept between the last injection of enoxaparin sodium at prophylactic doses and the needle or catheter placement.

For continuous techniques, a similar delay of at least 12 hours should be observed before removing the catheter.

For patients with creatinine clearance [15-30] mL/min, consider doubling the timing of puncture/catheter placement or removal to at least 24 hours.

The 2 hours preoperative initiation of enoxaparin sodium 2,000 IU (20 mg) is not compatible with neuraxial anaesthesia.

• At doses used for treatment

A puncture-free interval of at least 24 hours shall be kept between the last injection of enoxaparin sodium at curative doses and the needle or catheter placement (see also section 4.3).

For continuous techniques, a similar delay of 24 hours should be observed before removing the catheter.

For patients with creatinine clearance [15-30] mL/min, consider doubling the timing of puncture/catheter placement or removal to at least 48 hours.

Patients receiving the twice daily doses (i.e. 75 IU/kg (0.75 mg/kg) twice daily or 100 IU/kg (1 mg/kg) twice-daily) should omit the second enoxaparin sodium dose to allow a sufficient delay before catheter placement or removal.

Anti-Xa levels are still detectable at these time points, and these delays are not a guarantee that neuraxial hematoma will be avoided.

Likewise, consider not using enoxaparin sodium until at least 4 hours after the spinal/epidural puncture or after the catheter has been removed. The delay must be 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.

4.3. Contraindications

Enoxaparin sodium is contraindicated in patients with:

• Hypersensitivity to enoxaparin sodium, heparin or its derivatives, including other low molecular weight heparins (LMWH) or to any of the excipients listed in section 6.1;

• History of immune mediated heparin-induced thrombocytopenia (HIT) within the past 100 days or in the presence of circulating antibodies (see also section 4.4 );

• Active clinically significant bleeding and conditions with a high risk of haemorrhage, including recent haemorrhagic stroke, gastrointestinal ulcer, presence of malignant neoplasm at high risk of bleeding, recent brain, spinal or ophthalmic surgery, known or suspected oesophageal varices, arteriovenous malformations, vascular aneurysms or major intraspinal or intracerebral vascular abnormalities;

• Spinal or epidural anaesthesia or loco-regional anaesthesia when enoxaparin sodium is used for treatment in the previous 24 hours (see section 4.4).

4.4. Special warnings and precautions for use

Traceability

LMWHs are biological medicinal products. In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.

General

Enoxaparin sodium cannot be used interchangeably (unit for unit) with other LMWHs. These medicinal products differ in their manufacturing process, molecular weights, specific anti-Xa and anti-IIa activities, units, dose and clinical efficacy and safety. This results in differences in pharmacokinetics and associated biological activities (e.g. anti-thrombin activity, and platelet interactions). Special attention and compliance with the instructions for use specific to each proprietary medicinal product are therefore required.

History of HIT (>100 days)

Use of enoxaparin sodium in patients with a history of immune mediated HIT within the past 100 days or in the presence of circulating antibodies is contraindicated (see section 4.3). Circulating antibodies may persist several years.

Enoxaparin sodium is to be used with extreme caution in patients with a history (>100 days) of heparin-induced thrombocytopenia without circulating antibodies. The decision to use enoxaparin sodium in such a case must be made only after a careful benefit risk assessment and after non-heparin alternative treatments are considered (e.g. danaparoid sodium or lepirudin).

Monitoring of platelet counts

In patients with cancer with a platelet count below 80 G/L, anticoagulation treatment can only be considered on a case-by-case basis and careful monitoring is recommended.

The risk of antibody-mediated HIT also exists with LMWHs. Should thrombocytopenia occur, it usually appears between the 5th and the 21st day following the beginning of enoxaparin sodium treatment.

The risk of HIT is higher in postoperative patients and mainly after cardiac surgery and in patients with cancer.

Therefore, it is recommended that the platelet counts be measured before the initiation of therapy with enoxaparin sodium and then regularly thereafter during the treatment.

If there are clinical symptoms suggestive of HIT (any new episode of arterial and/or venous thromboembolism, any painful skin lesion at the injection site, any allergic or anaphylactoid reactions on treatment), platelet count should be measured. Patients must be aware that these symptoms may occur and if so, that they should inform their primary care physician.

In practice, if a confirmed significant decrease of the platelet count is observed (30 to 50 % of the initial value), enoxaparin sodium treatment must be immediately discontinued and the patient switched to another non-heparin anticoagulant alternative treatment.

Haemorrhage

As with other anticoagulants, bleeding may occur at any site. If bleeding occurs, the origin of the haemorrhage should be investigated and appropriate treatment instituted.

Enoxaparin sodium, as with any other anticoagulant therapy, should be used with caution in conditions with increased potential for bleeding, such as:

- impaired haemostasis,

- history of peptic ulcer,

- recent ischemic stroke,

- severe arterial hypertension,

- recent diabetic retinopathy,

- neuro- or ophthalmologic surgery,

- concomitant use of medicinal products affecting haemostasis (see section 4.5).

Laboratory tests

At doses used for prophylaxis of venous thromboembolism, enoxaparin sodium does not influence bleeding time and global blood coagulation tests significantly, nor does it affect platelet aggregation or binding of fibrinogen to platelets.

At higher doses, increases in activated partial thromboplastin time (aPTT), and activated clotting time (ACT) may occur. Increases in aPTT and ACT are not linearly correlated with increasing enoxaparin sodium antithrombotic activity and therefore are unsuitable and unreliable for monitoring enoxaparin sodium activity.

Spinal/Epidural anaesthesia or lumbar puncture

Spinal/epidural anaesthesia or lumbar puncture must not be performed within 24 hours of administration of enoxaparin sodium at therapeutic doses (see also section 4.3).

There have been cases of neuraxial haematomas reported with the concurrent use of enoxaparin sodium and spinal/epidural anaesthesia or spinal puncture procedures resulting in long term or permanent paralysis. These events are rare with enoxaparin sodium dose regimens 4,000 IU (40 mg) once daily or lower. The risk of these events is higher with the use of post-operative indwelling epidural catheters, with the concomitant use of additional medicinal products affecting haemostasis such as Non-Steroidal Anti‑Inflammatory Drugs (NSAIDs), with traumatic or repeated epidural or spinal puncture, or in patients with a history of spinal surgery or spinal deformity.

To reduce the potential risk of bleeding associated with the concurrent use of enoxaparin sodium and epidural or spinal anaesthesia/analgesia or spinal puncture, consider the pharmacokinetic profile of enoxaparin sodium (see section 5.2). Placement or removal of an epidural catheter or lumbar puncture is best performed when the anticoagulant effect of enoxaparin sodium is low; however, the exact timing to reach a sufficiently low anticoagulant effect in each patient is not known. For patients with creatinine clearance [15‑30 mL/minute], additional considerations are necessary because elimination of enoxaparin sodium is more prolonged (see section 4.2).

Should the physician decide to administer anticoagulation in the context of epidural or spinal anaesthesia/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), 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.

Skin necrosis/cutaneous vasculitis

Skin necrosis and cutaneous vasculitis have been reported with LMWHs and should lead to prompt treatment discontinuation.

Percutaneous coronary revascularization procedures

To minimise the risk of bleeding following the vascular instrumentation during the treatment of unstable angina, NSTEMI and acute STEMI, adhere precisely to the intervals recommended between enoxaparin sodium injection doses. It is important to achieve haemostasis at the puncture site after PCI. In case a closure device is used, the sheath can be removed immediately. If a manual compression method is used, sheath should be removed 6 hours after the last IV/SC enoxaparin sodium injection. If the treatment with enoxaparin sodium is to be continued, the next scheduled dose should be given no sooner than 6 to 8 hours after sheath removal. The site of the procedure should be observed for signs of bleeding or hematoma formation.

Acute infective endocarditis

Use of heparin is usually not recommended in patients with acute infective endocarditis due to the risk of cerebral haemorrhage. If such use is considered absolutely necessary, the decision must be made only after a careful individual benefit risk assessment.

Mechanical prosthetic heart valves

The use of enoxaparin sodium has not been adequately studied for thromboprophylaxis in patients with mechanical prosthetic heart valves. Isolated cases of prosthetic heart valve thrombosis have been reported in patients with mechanical prosthetic heart valves who have received enoxaparin sodium for thromboprophylaxis. Confounding factors, including underlying disease and insufficient clinical data, limit the evaluation of these cases. Some of these cases were pregnant women in whom thrombosis led to maternal and foetal death.

Pregnant women with mechanical prosthetic heart valves

The use of enoxaparin sodium for thromboprophylaxis in pregnant women with mechanical prosthetic heart valves has not been adequately studied. In a clinical study of pregnant women with mechanical prosthetic heart valves given enoxaparin sodium (100 IU/kg (1 mg/kg ) twice daily) to reduce the risk of thromboembolism, 2 of 8 women developed clots resulting in blockage of the valve and leading to maternal and foetal death. There have been isolated post-marketing reports of valve thrombosis in pregnant women with mechanical prosthetic heart valves while receiving enoxaparin sodium for thromboprophylaxis. Pregnant women with mechanical prosthetic heart valves may be at higher risk for thromboembolism.

Elderly

No increased bleeding tendency is observed in the elderly with the prophylactic dose ranges. Elderly patients (especially patients eighty years of age and older) may be at an increased risk for bleeding complications with the therapeutic dose ranges. Careful clinical monitoring is advised and dose reduction might be considered in patients older than 75 years treated for STEMI (see sections 4.2 and 5.2).

Renal impairment

In patients with renal impairment, there is an increase in exposure of enoxaparin sodium which increases the risk of bleeding. In these patients, careful clinical monitoring is advised, and biological monitoring by anti-Xa activity measurement might be considered (see sections 4.2 and 5.2).

Enoxaparin sodium is not recommended for patients with end stage renal disease (creatinine clearance <15 mL/min) due to lack of data in this population outside the prevention of thrombus formation in extra corporeal circulation during haemodialysis.

In patients with severe renal impairment (creatinine clearance 15-30 mL/min), since exposure of enoxaparin sodium is significantly increased, a dose adjustment is recommended for therapeutic and prophylactic dose ranges (see section 4.2).

No dose adjustment is recommended in patients with moderate (creatinine clearance 30-50 mL/min) and mild (creatinine clearance 50-80 mL/min) renal impairment.

Hepatic impairment

Enoxaparin sodium should be used with caution in patients with hepatic impairment due to an increased potential for bleeding. Dose adjustment based on monitoring of anti-Xa levels is unreliable in patients with liver cirrhosis and not recommended (see section 5.2).

Low weight

An increase in exposure of enoxaparin sodium with prophylactic doses (non-weight adjusted) has been observed in low-weight women (<45 kg) and low-weight men (<57 kg), which may lead to a higher risk of bleeding. Therefore, careful clinical monitoring is advised in these patients (see section 5.2).

Obese patients

Obese patients are at higher risk for thromboembolism. The safety and efficacy of prophylactic doses in obese patients (BMI >30 kg/m2) has not been fully determined and there is no consensus for dose adjustment. These patients should be observed carefully for signs and symptoms of thromboembolism.

Hyperkalaemia

Heparins can suppress adrenal secretion of aldosterone leading to hyperkalaemia (see section 4.8), particularly in patients such as those with diabetes mellitus, chronic renal failure, pre-existing metabolic acidosis, taking medicinal products known to increase potassium (see section 4.5). Plasma potassium should be monitored regularly especially in patients at risk.

Sodium content

This medicinal product contains less than 1 mmol sodium (23 mg) per dose, that is to say essentially 'sodium‑free'.

Acute generalized exanthematous pustulosis

Acute generalized exanthematous pustulosis (AGEP) has been reported with frequency not known in association with enoxaparin treatment. At the time of prescription patients should be advised of the signs and symptoms and monitored closely for skin reactions. If signs and symptoms suggestive of these reactions appear, enoxaparin should be withdrawn immediately and an alternative treatment considered (as appropriate).

4.5. Interaction with other medicinal products and other forms of interaction

Concomitant use not recommended

Medicinal products affecting haemostasis (see section 4.4)

It is recommended that some agents which affect haemostasis should be discontinued prior to enoxaparin sodium therapy unless strictly indicated. If the combination is indicated, enoxaparin sodium should be used with careful clinical and laboratory monitoring when appropriate. These agents include medicinal products such as:

- Systemic salicylates, acetylsalicylic acid at anti-inflammatory doses, and NSAIDs including ketorolac,

- Other thrombolytics (e.g. alteplase, reteplase, streptokinase, tenecteplase, urokinase) and anticoagulants (see section 4.2).

Concomitant use with caution

The following medicinal products may be administered with caution concomitantly with enoxaparin sodium:

• Other medicinal products affecting haemostasis such as:

- Platelet aggregation inhibitors including acetylsalicylic acid used at antiaggregant dose (cardioprotection), clopidogrel, ticlopidine, and glycoprotein IIb/IIIa antagonists indicated in acute coronary syndrome due to the risk of bleeding,

- Dextran 40,

- Systemic glucocorticoids.

• Medicinal products increasing potassium levels:

Medicinal products that increase serum potassium levels may be administered concurrently with enoxaparin sodium under careful clinical and laboratory monitoring (see sections 4.4 and 4.8).

4.6. Fertility, pregnancy and lactation

Pregnancy

In humans, there is no evidence that enoxaparin crosses the placental barrier during the second and third trimester of pregnancy. There is no information available concerning the first trimester.

Animal studies have not shown any evidence of foetotoxicity or teratogenicity (see section 5.3). Animal data have shown that enoxaparin passage through the placenta is minimal.

Enoxaparin sodium should be used during pregnancy only if the physician has established a clear need.

Pregnant women receiving enoxaparin sodium should be carefully monitored for evidence of bleeding or excessive anticoagulation and should be warned of the haemorrhagic risk. Overall, the data suggest that there is no evidence for an increased risk of haemorrhage, thrombocytopenia or osteoporosis with respect to the risk observed in non-pregnant women, other than that observed in pregnant women with prosthetic heart valves (see section 4.4).

If an epidural anaesthesia is planned, it is recommended to withdraw enoxaparin sodium treatment before (see section 4.4).

Breast‑feeding

It is not known whether unchanged enoxaparin is excreted in human breast milk. In lactating rats, the passage of enoxaparin or its metabolites in milk is very low. The oral absorption of enoxaparin sodium is unlikely. Inhixa can be used during breastfeeding.

Fertility

There are no clinical data for enoxaparin sodium in fertility. Animal studies did not show any effect on fertility (see section 5.3).

4.7. Effects on ability to drive and use machines

Enoxaparin sodium has no or negligible influence on the ability to drive and use machines.

4.8. Undesirable effects

Summary of the safety profile

Enoxaparin sodium has been evaluated in more than 15,000 patients who received enoxaparin sodium in clinical trials. These included 1,776 for prophylaxis of DVT following orthopaedic or abdominal surgery in patients at risk for thromboembolic complications, 1,169 for prophylaxis of DVT in acutely ill medical patients with severely restricted mobility, 559 for treatment of DVT with or without PE, 1,578 for treatment of unstable angina and non-Q-wave myocardial infarction and 10,176 for treatment of acute STEMI.

Enoxaparin sodium regimen administered during these clinical trials varies depending on indications. The enoxaparin sodium dose was 4,000 IU (40 mg) SC once daily for prophylaxis of DVT following surgery or in acutely ill medical patients with severely restricted mobility. In treatment of DVT with or without PE, patients receiving enoxaparin sodium were treated with either a 100 IU/kg (1 mg/kg) SC dose every 12 hours or a 150 IU/kg (1.5 mg/kg) SC dose once a day. In the clinical trials for treatment of unstable angina and non-Q-wave myocardial infarction, doses were 100 IU/kg (1 mg/kg) SC every 12 hours, and in the clinical study for treatment of acute STEMI enoxaparin sodium regimen was a 3,000 IU (30 mg) IV bolus followed by 100 IU/kg (1 mg/kg) SC every 12 hours.

In clinical trials, haemorrhages, thrombocytopenia and thrombocytosis were the most commonly reported reactions (see section 4.4 and 'Description of selected adverse reactions' below).

The safety profile of enoxaparin for extended treatment of DVT and PE in patients with active cancer is similar to its safety profile for the treatment of DVT and PE.

Acute generalized exanthematous pustulosis (AGEP) has been reported in association with enoxaparin treatment (see section 4.4).

Tabulated list of adverse reactions

Other adverse reactions observed in clinical trials and reported in post-marketing experience (* indicates reactions from post-marketing experience) are detailed below.

Frequencies are defined as follows: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1000 to < 1/100); rare (≥ 1/10,000 to <1/1,000); and very rare (< 1/10,000) or not known (cannot be estimated from available data). Within each system organ class, adverse reactions are presented in order of decreasing seriousness.

Blood and the lymphatic system disorders

Common: Haemorrhage, haemorrhagic anaemia*, thrombocytopenia, thrombocytosis

Rare: Eosinophilia*

Rare: Cases of immuno-allergic thrombocytopenia with thrombosis; in some of them thrombosis was complicated by organ infarction or limb ischaemia (see section 4.4).

Immune system disorders

Common: Allergic reaction

Rare: Anaphylactic/Anaphylactoid reactions including shock*

Nervous system disorders

Common: Headache*

Vascular disorders

Rare: Spinal haematoma* (or neuraxial haematoma). These reactions have resulted in varying degrees of neurologic injuries including long-term or permanent paralysis (see section 4.4).

Hepatobiliary disorders

Very common: Hepatic enzyme increases (mainly transaminases > 3 times the upper limit of normality)

Uncommon: Hepatocellular liver injury *

Rare: Cholestatic liver injury*

Skin and subcutaneous tissue disorders

Common: Urticaria, pruritus, erythema

Uncommon: Bullous dermatitis

Rare: Alopecia*

Rare: Cutaneous vasculitis*, skin necrosis* usually occurring at the injection site (these phenomena have been usually preceded by purpura or erythematous plaques, infiltrated and painful).

Injection site nodules* (inflammatory nodules, which were not cystic enclosure of enoxaparin). They resolve after a few days and should not cause treatment discontinuation.

Not known: Acute generalized exanthematous pustulosis (AGEP)

Musculoskeletal and connective tissue disorders

Rare: Osteoporosis* following long term therapy (greater than 3 months)

General disorders and administration site conditions

Common: Injection site haematoma, injection site pain, other injection site reaction (such as oedema, haemorrhage, hypersensitivity, inflammation, mass, pain, or reaction)

Uncommon: Local irritation, skin necrosis at injection site

Investigations

Rare: Hyperkalaemia* (see sections 4.4 and 4.5).

Description of selected adverse reactions

Haemorrhages

These included major haemorrhages, reported at most in 4.2 % of the patients (surgical patients). Some of these cases have been fatal. In surgical patients, haemorrhage complications were considered major: (1) if the haemorrhage caused a significant clinical event, or (2) if accompanied by haemoglobin decrease ≥ 2 g/dL or transfusion of 2 or more units of blood products. Retroperitoneal and intracranial haemorrhages were always considered major.

As with other anticoagulants, haemorrhage may occur in the presence of associated risk factors such as: organic lesions liable to bleed, invasive procedures or the concomitant use of medicinal products affecting haemostasis (see sections 4.4 and 4.5).

System organ class

Prophylaxis in surgical patients

Prophylaxis in medical patients

Treatment in patients with DVT with or without PE

Extended treatment of DVT and PE in patients with active cancer

Treatment in patients with unstable angina and non-Q-wave MI

Treatment in patients with acute STEMI

Blood and lymphatic system disorders

Very common:

Haemorrhage α

Rare:

Retroperitoneal haemorrhage

Common:

Haemorrhage α

Very common:

Haemorrhage α

Uncommon:

Intracranial haemorrhage, Retroperitoneal haemorrhage

Common b:

Haemorrhage

Common:

Haemorrhage α

Rare:

Retroperitoneal haemorrhage

Common:

Haemorrhage α

Uncommon:

Intracranial haemorrhage, Retroperitoneal haemorrhage

α: such as haematoma, ecchymosis other than at injection site, wound haematoma, haematuria, epistaxis and gastro‑intestinal haemorrhage.

b: frequency based on a retrospective study on a registry including 3526 patients (see section 5.1)

Thrombocytopenia and thrombocytosis (see section 4.4 monitoring of platelet counts)

System organ class

Prophylaxis in surgical patients

Prophylaxis in medical patients

Treatment in patients with DVT with or without PE

Extended treatment of DVT and PE in patients with active cancer

Treatment in patients with unstable angina and non-Q-wave MI

Treatment in patients with acute STEMI

Blood and lymphatic system disorders

Very common:

Thrombocytosisβ

Common:

Thrombo-cytopenia

Uncommon:

Thrombo-cytopenia

Very common:

Thrombocytosisβ

Common:

Thrombo-cytopenia

Unknown:

Thrombocytopenia

Uncommon: Thrombo-cytopenia

Common:

Thrombocytosisβ Thrombo-cytopenia

Very rare:

Immuno-allergic thrombo-cytopenia

β: Platelet increased >400 G/L

Paediatric population

The safety and efficacy of enoxaparin sodium in children have not been established (see section 4.2).

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Signs and symptoms

Accidental overdose with enoxaparin sodium after IV, extracorporeal or SC administration may lead to haemorrhagic complications. Following oral administration of even large doses, it is unlikely that enoxaparin sodium will be absorbed.

Management

The anticoagulant effects can be largely neutralised by the slow IV injection of protamine. The dose of protamine depends on the dose of enoxaparin sodium injected; 1 mg protamine neutralises the anticoagulant effect of 100 IU (1 mg) of enoxaparin sodium, if enoxaparin sodium was administered in the previous 8 hours. An infusion of 0.5 mg protamine per 100 IU (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. After 12 hours of the enoxaparin sodium injection, protamine administration may not be required. However, even with high doses of protamine, the anti-Xa activity of enoxaparin sodium is never completely neutralised (maximum about 60%) (see the prescribing information for protamine salts).