Injectable Anticoagulants - Low Molecular Weight Heparins (LMWH)

FRAGMINR(dalteparin) / INNOHEPR (tinzaparin) / LOVENOXR(enoxaparin) / ARIXTRAR(fondaparinux)

Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.

Key:

X: FDA approved indication
*Sufficient data exists to support off-label use

 

FDA Approved Indications:

                         Summary of FDA Approved Indications

Indications Fragmin Innohep Lovenox Arixtra
Prophylaxis of DVT that may lead to PE        
         
In abdominal surgery X   X X
In hip replacement X * X X
In knee replacement * * X X
In patients with severely restricted mobility during acute illness X   X  
In moderate risk surgery patients   *    
In high risk surgery patients * * *  
In orthopedic surgery * *   *
In hip fracture surgery * * * X
In neurosurgery   *    
In major trauma * * *  
In acute spinal cord injury * * *  
In ischemic stroke with impaired mobility * * *  
In general medical patients at risk (CHF, cancer, severe lung disease, restricted to bed) * * * *
In pregnancy related thromboembolism * * *  
Treatment of VTE with warfarin * X X X
Treatment of acute PE with warfarin       X
Extended treatment of symptomatic VTE in patients with cancer X      
Prophylaxis of ischemic complications in unstable agina and non-Q-wave MI X   X *
Acute ST-segment elevated myocardial infarction (STEMI)     X *
Percutaneous angioplasty, acute coronary syndrome * * * *
Anticoagulation for dialysis     *  
Bridging to and from oral anticoagulation     X  

 

Western Health Advantage Approved Indications and Usage Guidelines:

Western Health Advantage considers the use of low-molecular-weight heparins (LMWHs) medically appropriate in clinical settings in which they have been found to offer improved safety and efficacy over unfractionated heparins (UFHs). Consistent with recommendations from the American College of Chest Physicians conference on antithrombotic and thrombolytic therapy evidence-based guidelines published in Chest.

Western Health Advantage approves coverage of LMWHs for the following indications:

  • Western Health Advantage covers LMWHs consistent with recommendations from the American College of Chest Physicians conference on antithrombotic and thrombolytic therapy evidence-based guidelines published in Chest.
  • Use as short-term, preoperative therapy when a member on oral anticoagulation needs to be put on a drug with a shorter duration of action prior to surgery or as prophylaxis or treatment as a transition to oral anticoagulation
  • Treatment of venous thrombosis and prophylaxis of extension of venous thrombosis when inpatient care can be diverted to an outpatient setting
  • Western Health Advantage discourages the use of Innohep for self administration as it is not available in a pre-drawn syringe and requires the patient to draw up the medication, predisposing the patient to unneeded risks.

Coverage is Not Authorized For:

  • Anticoagulation when there are no known contraindications to oral anticoagulant therapy
  • Patients with low-risk for VTE from surgical procedures not mentioned above
  • Arterial thrombosis except for acute coronary syndrome
  • Femoral-popliteal graft patency
  • Patients with active major bleeding
  • Pregnancy with a mechanical heart valve unless dose adjusted to recommended anti-factor Xa levels
  • Treatment of cancer for reasons other than prevention/treatment of recurrent VTE
  • Subarachnoid hemorrhage
  • Non-FDA approved indications, which are not listed in the Western Health Advantage Approved Indications and Usage Guidelines section unless there is sufficient documentation of efficacy and safety in the published literature

 

 

Last review date: July 21, 2016