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Kongsawat K, Chaivanijchaya K, Pakul F, Joradol S, Kachornvitaya P, Boonchaya-Anant P, Udomsawaengsup S. Comparison of enoxaparin 40 mg versus 60 mg dosage for venous thromboprophylaxis in patients undergoing bariatric surgery: A randomized controlled trial. Asian J Surg 2024:S1015-9584(24)00357-9. [PMID: 38514281 DOI: 10.1016/j.asjsur.2024.02.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/02/2023] [Accepted: 02/16/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common cause of morbidity and mortality after bariatric surgery. Morbid obesity is an independent risk factor for VTE, with goals of prophylactic anti-factor Xa levels within 0.2-0.5 IU/mL. The recommended dosing regimen of enoxaparin for VTE prophylaxis in patients with morbid obesity is lacking in available guidelines. OBJECTIVES To evaluate the achieving prophylactic anti-factor Xa levels with different dosages of enoxaparin for morbid obesity patients. SETTING We conducted a study at Chulalongkorn Bariatric and Metabolic Institute, King Chulalongkorn Memorial Hospital. METHODS We conducted a randomized controlled trial comparing anti-factor Xa levels 4 h after the administration of enoxaparin. All recruited patients randomly received 40 mg or 60 mg of enoxaparin 12 h before the operation. Blood specimens were collected 4 h after the administration of enoxaparin. RESULTS In total, 56 patients who presented between April 2019 and March 2020 at King Chulalongkorn Memorial Hospital were recruited. Of these patients, 28 received 40 mg and 28 received 60 mg of enoxaparin. In both groups, the rates of achieving target levels were 53.57% and 78.57%, respectively (p-value = 0.048). The mean anti-factor Xa levels were 0.19 IU/mL ± 0.06 IU/mL and 0.28 and 0.28 ± 0.10 IU/mL, respectively (p < 0.001). No significant difference was found in the estimated blood loss between the groups. No patient obtained anti-factor Xa levels exceeding 0.5 IU/mL. In both groups, no symptomatic VTE occurred. CONCLUSIONS A 60 mg of enoxaparin regimen achieved more prophylactic anti-factor Xa levels than 40 mg in obese patients undergoing bariatric surgery without any adverse events.
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Affiliation(s)
- Kritsada Kongsawat
- Department of Surgery, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Komol Chaivanijchaya
- Department of Surgery, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Fon Pakul
- Department of Surgery, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Suthikiat Joradol
- Department of Surgery, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Pattharasai Kachornvitaya
- Department of Surgery, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Patchaya Boonchaya-Anant
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Suthep Udomsawaengsup
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Treatment of Obesity and Metabolic Disease Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Cross B, Turner RM, Zhang JE, Pirmohamed M. Being precise with anticoagulation to reduce adverse drug reactions: are we there yet? Pharmacogenomics J 2024; 24:7. [PMID: 38443337 PMCID: PMC10914631 DOI: 10.1038/s41397-024-00329-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/11/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
Anticoagulants are potent therapeutics widely used in medical and surgical settings, and the amount spent on anticoagulation is rising. Although warfarin remains a widely prescribed oral anticoagulant, prescriptions of direct oral anticoagulants (DOACs) have increased rapidly. Heparin-based parenteral anticoagulants include both unfractionated and low molecular weight heparins (LMWHs). In clinical practice, anticoagulants are generally well tolerated, although interindividual variability in response is apparent. This variability in anticoagulant response can lead to serious incident thrombosis, haemorrhage and off-target adverse reactions such as heparin-induced thrombocytopaenia (HIT). This review seeks to highlight the genetic, environmental and clinical factors associated with variability in anticoagulant response, and review the current evidence base for tailoring the drug, dose, and/or monitoring decisions to identified patient subgroups to improve anticoagulant safety. Areas that would benefit from further research are also identified. Validated variants in VKORC1, CYP2C9 and CYP4F2 constitute biomarkers for differential warfarin response and genotype-informed warfarin dosing has been shown to reduce adverse clinical events. Polymorphisms in CES1 appear relevant to dabigatran exposure but the genetic studies focusing on clinical outcomes such as bleeding are sparse. The influence of body weight on LMWH response merits further attention, as does the relationship between anti-Xa levels and clinical outcomes. Ultimately, safe and effective anticoagulation requires both a deeper parsing of factors contributing to variable response, and further prospective studies to determine optimal therapeutic strategies in identified higher risk subgroups.
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Affiliation(s)
- Benjamin Cross
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Richard M Turner
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
- GSK, Stevenage, Hertfordshire, SG1 2NY, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
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Amin A, Kartashov A, Ngai W, Steele K, Rosenthal N. Effectiveness, safety, and costs of thromboprophylaxis with enoxaparin or unfractionated heparin in inpatients with obesity. Front Cardiovasc Med 2023; 10:1163684. [PMID: 37396589 PMCID: PMC10313352 DOI: 10.3389/fcvm.2023.1163684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/08/2023] [Indexed: 07/04/2023] Open
Abstract
Background Obesity is a frequent and significant risk factor for venous thromboembolism (VTE) among hospitalized adults. Pharmacologic thromboprophylaxis can help prevent VTE, but real-world effectiveness, safety, and costs among inpatients with obesity are unknown. Objective This study aims to compare clinical and economic outcomes among adult medical inpatients with obesity who received thromboprophylaxis with enoxaparin or unfractionated heparin (UFH). Methods A retrospective cohort study was performed using the PINC AI™ Healthcare Database, which covers more than 850 hospitals in the United States. Patients included were ≥18 years old, had a primary or secondary discharge diagnosis of obesity [International Classification of Diseases (ICD)-9 diagnosis codes 278.01, 278.02, and 278.03; ICD-10 diagnosis codes E66.0x, E66.1, E66.2, E66.8, and E66.9], received ≥1 thromboprophylactic dose of enoxaparin (≤40 mg/day) or UFH (≤15,000 IU/day) during the index hospitalization, stayed ≥6 days in the hospital, and were discharged between 01 January 2010, and 30 September 2016. We excluded surgical patients, patients with pre-existing VTE, and those who received higher (treatment-level) doses or multiple types of anticoagulants. Multivariable regression models were constructed to compare enoxaparin with UFH based on the incidence of VTE, pulmonary embolism (PE)---------related mortality, overall in-hospital mortality, major bleeding, treatment costs, and total hospitalization costs during the index hospitalization and the 90 days after index discharge (readmission period). Results Among 67,193 inpatients who met the selection criteria, 44,367 (66%) and 22,826 (34%) received enoxaparin and UFH, respectively, during their index hospitalization. Demographic, visit-related, clinical, and hospital characteristics differed significantly between groups. Enoxaparin during index hospitalization was associated with 29%, 73%, 30%, and 39% decreases in the adjusted odds of VTE, PE-related mortality, in-hospital mortality, and major bleeding, respectively, compared with UFH (all p < 0.002). Compared with UFH, enoxaparin was associated with significantly lower total hospitalization costs during the index hospitalization and readmission periods. Conclusions Among adult inpatients with obesity, primary thromboprophylaxis with enoxaparin compared with UFH was associated with significantly lower risks of in-hospital VTE, major bleeding, PE-related mortality, overall in-hospital mortality, and hospitalization costs.
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Affiliation(s)
- Alpesh Amin
- Department of Medicine, University of California at Irvine, Irvine, CA, United States
| | - Alex Kartashov
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, NC, United States
| | | | | | - Ning Rosenthal
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, NC, United States
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Al Tannir AH, Biesboer EA, Pokrzywa CJ, Figueroa J, Harding E, de Moya MA, Morris RS, Murphy PB. The efficacy of various Enoxaparin dosing regimens in general surgery patients: A systematic review. Surgery 2023:S0039-6060(23)00208-8. [PMID: 37198037 DOI: 10.1016/j.surg.2023.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Patients undergoing surgical procedures are at an increased risk of venous thromboembolism events. A fixed Enoxaparin dosing regimen is the standard of care for chemoprophylaxis in most institutions; however, breakthrough venous thromboembolism events are still reported. We aimed to systematically review the literature to determine the ability of various Enoxaparin dosing regimens to achieve adequate prophylactic anti-Xa levels for venous thromboembolism prevention in hospitalized general surgery patients. Additionally, we aimed to assess the correlation between subprophylactic anti-Xa levels and the development of clinically significant venous thromboembolism events. METHODS A systematic review was conducted using major databases from January 1, 1993, to February 17, 2023. Two independent researchers screened titles and abstracts, followed by a full-text review. Articles were included if Enoxaparin dosing regimens were evaluated by anti-Xa levels. Exclusion criteria included systematic reviews, pediatric population, nongeneral surgery (defined as trauma, orthopedics, plastics, and neurosurgery), and non-Enoxaparin chemoprophylaxis. The primary outcome was peak Anti-Xa level measured at steady state concentration. The risk of bias was assessed using the Risk of Bias in Nonrandomized studies-of Intervention tool. RESULTS A total of 6,760 articles were extracted, of which 19 were included in the scoping review. Nine studies included bariatric patients, whereas 5 studies explored abdominal surgical oncology patients. Three studies assessed thoracic surgery patients, and 2 studies included patients undergoing "general surgery" procedures. A total of 1,502 patients were included. The mean age was 47 years, and 38% were males. The percentages of patients reaching adequate prophylactic anti-Xa levels were 39%, 61%, 15%, 50%, and 78% across the 40 mg daily, 40 mg twice daily, 30 mg twice daily, and weight-tiered, and body mass index-based groups, respectively. The overall risk of bias was low to moderate. CONCLUSION Fixed Enoxaparin dosing regimens are not correlated with adequate anti-Xa levels in general surgery patients. Additional research is warranted to assess the efficacy of dosing regimens based on novel physiologic parameters (such as estimated blood volume).
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Affiliation(s)
- Abdul Hafiz Al Tannir
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Elise A Biesboer
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Courtney J Pokrzywa
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Juan Figueroa
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Eric Harding
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Marc A de Moya
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Rachel S Morris
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Patrick B Murphy
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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Nemeth A, Isherwood M. Safety and Effectiveness of Reduced Dose Versus Standard Dose Enoxaparin Venous Thromboembolism Prophylaxis in Underweight Medically Ill Patients. Hosp Pharm 2023; 58:178-182. [PMID: 36890953 PMCID: PMC9986578 DOI: 10.1177/00185787221123220] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Enoxaparin is commonly used for venous thromboembolism (VTE) prophylaxis in hospitalized patients. Published literature exists for dose adjustment in higher body weights and renal dysfunction, but sparse literature on optimal dosing of prophylactic enoxaparin in underweight patients exists. Objective: To determine if there is a difference in adverse outcomes or effectiveness if enoxaparin VTE prophylaxis dosing is reduced to 30 mg subcutaneously once daily from standard dosing in underweight medically ill patients. Methods: This study was a retrospective chart review of a total of 171 patients, with 190 individual courses of enoxaparin included. Patients were ≥18 years of age, weighed ≤50 kg, and were given at least 2 days of consecutive therapy. Patients were excluded if they were taking anticoagulation upon admission, had a creatinine clearance <30 mL/min, were admitted to the ICU or a trauma or surgical service, or presented with bleeding or thrombosis. The Padua score and a modified score from the IMPROVE trial were used to evaluate baseline thrombotic risk and bleeding risk, respectively. Bleeding events were classified using the Bleeding Academic Research Consortium criteria. Results: No difference was seen in baseline risk of bleeding or thrombosis when comparing the reduced and standard dosing groups. No differences were observed with rates of bleeding, thrombotic events, mortality, or 30-day readmission. Conclusion: Both reduced and standard dosing strategies appeared effective for VTE prophylaxis, but neither showed superiority in reducing bleeding events. Additional larger studies are needed to evaluate safety and effectiveness of reduced dose of enoxaparin in this patient population.
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Affiliation(s)
- Abigail Nemeth
- Penn State Health/Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Manuel Isherwood
- Penn State Health/Milton S. Hershey Medical Center, Hershey, PA, USA
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Pfrepper C, Koch E, Weise M, Siegemund R, Siegemund A, Petros S, Metze M. Weight-adjusted dosing of tinzaparin for thromboprophylaxis in obese medical patients. Res Pract Thromb Haemost 2023; 7:100054. [PMID: 36876282 PMCID: PMC9975291 DOI: 10.1016/j.rpth.2023.100054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 12/02/2022] [Accepted: 12/30/2022] [Indexed: 01/21/2023] Open
Abstract
Background The optimal dose of tinzaparin for prophylaxis in obese medical patients is not well defined. Objectives To evaluate the anti-Xa activity in obese medical patients on tinzaparin prophylaxis adjusted for actual bodyweight. Methods Patients with a body mass index of ≥30 kg/m2 treated with 50 IU/kg tinzaparin once daily were prospectively included. Anti-Xa and anti-IIa activity; von Willebrand factor antigen and von Willebrand activity; factor VIII activity; D-dimer, prothrombin fragments; and thrombin generation were measured 4 hours after subcutaneous injection between days 1 and 14 after the initiation of tinzaparin prophylaxis. Results We included 121 plasma samples from 66 patients (48.5% women), with a median weight of 125 kg (range, 82-300 kg) and a median body mass index of 41.9 kg/m2 (range, 30.1-88.6 kg/m2). The target anti-Xa activity of 0.2 to 0.4 IU/mL was achieved in 80 plasma samples (66.1%); 39 samples (32.2%) were below and 2 samples (1.7%) above the target range. The median anti-Xa activity was 0.25 IU/mL (IQR, 0.19-0.31 IU/mL), 0.23 IU/mL (IQR, 0.17-0.28 IU/mL), and 0.21 IU/mL (IQR, 0.17-0.25 IU/mL) on days 1 to 3, days 4 to 6, and days 7 to 14, respectively. The anti-Xa activity did not differ among the weight groups (P = .19). Injection into the upper arm compared to the abdomen resulted in a lower endogenous thrombin potential, a lower peak thrombin, and a trend to a higher anti-Xa activity. Conclusion Dosing of tinzaparin adjusted for actual bodyweight in obese patients achieved anti-Xa activity in the target range for most patients, without accumulation or overdosing. In addition, there is a significant difference in thrombin generation depending on the injection site.
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Affiliation(s)
- Christian Pfrepper
- Division of Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Elisabeth Koch
- Division of Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Maria Weise
- Division of Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | | | - Annelie Siegemund
- Division of Hemostaseology, University Hospital Leipzig, Leipzig, Germany.,Medical ICU, University Hospital Leipzig, Leipzig, Germany
| | - Sirak Petros
- Division of Hemostaseology, University Hospital Leipzig, Leipzig, Germany.,Medical ICU, University Hospital Leipzig, Leipzig, Germany
| | - Michael Metze
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
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Muacevic A, Adler JR, Al Harb S, Al Dughayem N, Al Harthi K, Gramish J. The Pattern of Heparin Dosing as Venous Thromboembolism Prophylaxis in Adult Underweight Patients Admitted to Critical Care Units at a Tertiary Hospital. Cureus 2022; 14:e31717. [PMID: 36569710 PMCID: PMC9768557 DOI: 10.7759/cureus.31717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is one of the causes of hospital-related deaths in critically ill patients. Guidelines recommended VTE prophylaxis with standardized, fixed doses for most patients. The underweight population has limited data to guide the appropriate drug and dosing regimen. OBJECTIVE The aim of this study was to describe the pattern of VTE prophylaxis dose regimens for underweighted critically ill adult patients and the prevalence of associated VTE and bleeding. METHODS This study is a retrospective cohort study, conducted at the King Abdulaziz Medical City, Riyadh, Saudi Arabia. It included all critical patients admitted to the intensive care units (ICUs) and were above 14 years old with weight less than 50 kg or body mass index (BMI) of 18.5 kg/m2 or less, and were on heparin as VTE prophylaxis for more than 72 h from January 2016 until January 2020. RESULTS After screening 270 patients, only 40 patients were included in this study according to our inclusion and exclusion criteria. Only six patients (15%) received VTE prophylaxis as an adjusted dose of heparin 2500 U Q12, while the rest of the patients were taking standard dosing of heparin; 5000 U Q12 was given to 21 (52.50%) patients, and 5000 U Q8 was given to 13 (32.50%) patients. None of the adjusted doses developed any complications such as VTE or bleeding. There was no significant difference compared with the standard dose group. CONCLUSIONS In this study, we described the pattern of heparin doses as VTE prophylaxis in underweight patients. We also compared the standard dosing and adjusted dosage of VTE prophylaxis on underweight patients and any complications. There was no significant difference in the complications outcome or benefits between the two groups.
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Bruno AM, Allshouse AA, Campbell HM, Branch DW, Lim MY, Silver RM, Metz TD. Weight-Based Compared With Fixed-Dose Enoxaparin Prophylaxis After Cesarean Delivery: A Randomized Controlled Trial. Obstet Gynecol 2022; 140:575-583. [PMID: 36075079 PMCID: PMC10473241 DOI: 10.1097/aog.0000000000004937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/14/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To evaluate fixed compared with weight-based enoxaparin dosing to achieve prophylactic anti-Xa levels after cesarean delivery. METHODS Individuals meeting institutional criteria for enoxaparin thromboprophylaxis after cesarean delivery were randomly allocated to fixed (40 mg daily for body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] lower than 40; 40 mg every 12 hours for BMI 40 or higher) or weight-based (0.5 mg/kg every 12 hours) enoxaparin dosing. Enoxaparin was initiated during inpatient hospitalization and continued at discharge for 14 days. Those with contraindication to anticoagulation, plan for therapeutic anticoagulation, or known renal impairment were excluded. The trial was unmasked. The primary outcome was prophylactic (0.2-0.6 international units/mL) peak anti-Xa level 4-6 hours after at least the third enoxaparin dose (at steady state). Secondary outcomes included subprophylactic and supraprophylactic peaks, outpatient peak, and venous thromboembolism (VTE) and wound complications in the first 6 weeks postpartum. Sample size of 121 per group was planned. At interim analysis with 50% enrollment, the trial was stopped early for efficacy. Primary analyses followed intention-to-treat principle with worst-case imputation for missing outcomes. Secondary analyses were complete case. RESULTS From June 2020 to November 2021, 74 individuals were randomized to weight-based enoxaparin and 72 to fixed-dose enoxaparin. Those who received weight-based dosing were more likely to achieve prophylactic anti-Xa levels than those who received fixed dosing in primary analysis (49/74 [66%] vs 32/72 [44%], relative risk [RR] 1.49, 95% CI 1.10-2.02) and secondary analysis (49/60 [82%] vs 32/57 [56%], RR 1.45, 95% CI 1.12-1.88). Subprophylactic levels occurred more frequently with fixed dosing; supraprophylactic levels did not differ significantly by dosing. At the outpatient postoperative visit, 52% of participants (15/29) with weight-based dosing compared with 15% (5/33) with fixed dosing achieved prophylactic peak anti-Xa level (RR 3.41, 95% CI 1.42-8.24). There were no VTEs in either group. Wound complications occurred in five individuals (7%) with weight-based enoxaparin dosing compared with one individual (1%) with fixed enoxaparin dosing (RR 4.86, 95% 0.58-40.63). CONCLUSION Weight-based dosing was more effective than fixed enoxaparin dosing in achieving prophylactic peak anti-Xa levels after cesarean delivery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04305756.
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Affiliation(s)
- Ann M. Bruno
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Murray, UT
| | | | - Heather M. Campbell
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Murray, UT
| | - D. Ware Branch
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Murray, UT
| | - Ming Y. Lim
- University of Utah Health, Salt Lake City, UT
| | - Robert M. Silver
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Murray, UT
| | - Torri D. Metz
- University of Utah Health, Salt Lake City, UT
- Intermountain Healthcare, Murray, UT
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O’Keefe MM, Carver TW, Herrmann DJ, Prom A, Hubbard S, Rein LE, Peppard WJ. Evaluation of anti‐factor Xa concentrations using a body mass index‐based enoxaparin dosing protocol for venous thromboembolism prophylaxis in trauma patients. Pharmacotherapy 2022; 42:216-223. [DOI: 10.1002/phar.2665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/24/2021] [Accepted: 01/02/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Mary M. O’Keefe
- Department of Pharmacy Salem Health Hospitals Salem Oregon USA
| | - Thomas W. Carver
- Department of Surgery Division of Trauma and Critical Care Medical College of Wisconsin Milwaukee Wisconsin USA
| | - David J. Herrmann
- Department of Pharmacy Froedtert & the Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Alyson Prom
- Department of Pharmacy University of North Carolina Health Chapel Hill North Carolina USA
| | - Sara Hubbard
- Department of Pharmacy Froedtert & the Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Lisa E. Rein
- Institute for Health & Equality Division of Biostatistics Medical College of Wisconsin Milwaukee Wisconsin USA
| | - William J. Peppard
- Department of Surgery Division of Trauma and Critical Care Medical College of Wisconsin Milwaukee Wisconsin USA
- Department of Pharmacy Froedtert & the Medical College of Wisconsin Milwaukee Wisconsin USA
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Baloo MM, Scribante J, Perrie H, Calleemalay D, Omar S. Factor Xa Levels in Patients Receiving Prophylactic Enoxaparin Sodium in the Intensive Care Unit of an Academic Hospital. Indian J Crit Care Med 2021; 25:917-919. [PMID: 34733033 PMCID: PMC8559763 DOI: 10.5005/jp-journals-10071-23879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: The aim of this study was to determine the anti-factor Xa levels in patients receiving enoxaparin sodium for venous thromboembolism prophylaxis in the intensive care unit (ICU). Patients and methods: Using a cross-sectional study methodology, 73 ICU patients receiving 40 mg enoxaparin sodium daily were enrolled in this study. Anti-factor Xa levels were measured following the second dose. Prophylactic and subprophylactic groups of patients were compared for age, sex, weight, body mass index, total bilirubin, serum albumin, and APACHE II score. Results: Anti-factor Xa levels were prophylactic (0.2–0.6 IU/mL) in 44 (60.3%) patients and subprophylactic (<0.2 IU/mL) in 29 (39.7%) patients. The mean (SD) actual delivered dose of enoxaparin per kilogram body weight was significantly higher, at 0.59 (0.11) mg/kg in the prophylactic group compared to 0.53 (0.13) mg/kg in the subprophylactic group (p = 0.043). The subprophylactic group had significantly lower serum albumin levels compared to the prophylactic group. The total bilirubin levels were not found to be significantly different between the two groups (p = 0.110). Conclusion: A fixed prophylactic 40 mg dose of enoxaparin was associated with a high proportion of subprophylactic anti-factor Xa levels. Weight-based dose and serum albumin level were independent predictors of achieving the prophylactic target range. How to cite this article: Baloo MM, Scribante J, Perrie H, Calleemalay D, Omar S. Factor Xa Levels in Patients Receiving Prophylactic Enoxaparin Sodium in the Intensive Care Unit of an Academic Hospital. Indian J Crit Care Med 2021;25(8):917–919.
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Affiliation(s)
- Mayank M Baloo
- Department of Anaesthesiology and Critical Care, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Juan Scribante
- Department of Anaesthesiology and Critical Care, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Helen Perrie
- Department of Anaesthesiology and Critical Care, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Daren Calleemalay
- Department of Critical Care, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Shahed Omar
- Department of Critical Care, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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Ferrill MJ, FakhriRavari A, Hong L, Wedret JJ. A Focus on Evaluating Major Study Limitations in Order to Apply Clinical Trials to Patient Care: Implications for the Healthcare Team. Hosp Pharm 2021; 56:597-603. [PMID: 34720166 DOI: 10.1177/0018578720931750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: With more than a million new biomedical articles published annually, healthcare providers must stay up to date in order to provide optimal evidence-based patient care. The concise ROOTs (relevance, observe validity, obtain clinically significant results, and translate results to clinical practice) format is a valuable tool to assist with literature evaluation. Purpose: To illustrate how major study limitations found in clinical trials might inhibit the ability to adopt the findings of such studies to patient care. Methods: Examples from published clinical trials that contain major study flaws were used to illustrate, if taken at face value, would lead to erroneous assumptions, and if adopted, could potentiallly harm patients. Conclusion: When evaluating the literature, it is crucial to identify limitations in the published literature that might reduce the internal validity, affect the results, or limit the external validity of clinical trials, hence affecting the usability of literature for patient care. This article provides examples of clinical trials that contain major study limitations with potentially erroneous assumptions. These illustrations are meant to show how important it is to delve deeper into an article before conclusions are drawn.
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Affiliation(s)
| | | | - Lisa Hong
- Loma Linda University, Loma Linda, CA, USA
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13
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Martin AM, Polistena P, Mahmud A, Bettridge B, Morling A, Chuah H, Yong ASM, Leahy MF. Optimal enoxaparin dosing strategies for venous thromboembolism prophylaxis and treatment of high body weight patients. Thromb Res 2021; 207:116-122. [PMID: 34619448 DOI: 10.1016/j.thromres.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/23/2021] [Accepted: 09/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Obesity is a risk factor for developing venous thromboembolism (VTE). Optimal dosage of enoxaparin has not been established in the obese population. We aimed to study clinical outcomes and complications with enoxaparin in obese patients. METHODS A retrospective, single centre observational study of obese patients treated with enoxaparin for VTE (n = 47) using a body mass index (BMI)-stratified dosing, thromboprophylaxis (n = 46), and non-obese controls (n = 20) was performed. Anti-Xa was used to measure enoxaparin efficacy. RESULTS Patients with a median BMI of 36.3 kg/m2 (range 30-52.7) with a median weight of 136 kg (range 68-240) received therapeutic enoxaparin at median 120 mg BID (range 60-200). A median targeted anti-Xa level of 0.79 (95% CI 0.72-1.03) IU/mL was achieved in 58% of patients. Dose reduction, or increase was needed in 25%, and 16% patients respectively. Mild or major haemorrhage, or VTE occurred in 10%, 2% and 2% patients respectively. Patients with a median weight of 160 kg (range 130-245) received thromboprophylaxis with 40 mg BID enoxaparin. Targeted median anti-Xa of 0.22 IU/mL (95% CI 0.19-0.24) was achieved in 59% patients. Mild haemorrhage was seen in 2%, while none developed major haemorrhage or VTE. Control patients who received enoxaparin 40 mg daily did not develop VTE; 5% had minor bleeding events. CONCLUSIONS BMI-stratified therapeutic enoxaparin dosing regimen is safe and effective therapy in obese patients. Fixed dosing without monitoring may not be appropriate. Thromboprophylaxis with 40 mg BID in obese patients was efficacious in preventing VTE without excess bleeding compared to control patients.
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Affiliation(s)
- Annalise M Martin
- Royal Perth Hospital, Perth, Western Australia, Australia; School of Cancer Biology, University of Western Australia, Western Australia, Australia.
| | | | - Asma Mahmud
- Royal Perth Hospital, Perth, Western Australia, Australia
| | - Brett Bettridge
- PathWest Laboratory Medicine, Perth, Western Australia, Australia
| | - Alan Morling
- PathWest Laboratory Medicine, Perth, Western Australia, Australia
| | - Hun Chuah
- Royal Perth Hospital, Perth, Western Australia, Australia; School of Cancer Biology, University of Western Australia, Western Australia, Australia
| | - Agnes S M Yong
- Royal Perth Hospital, Perth, Western Australia, Australia; Division of Pathology and Laboratory, University of Western Australia Medical School, Western Australia, Australia
| | - Michael F Leahy
- Royal Perth Hospital, Perth, Western Australia, Australia; PathWest Laboratory Medicine, Perth, Western Australia, Australia; Division of Pathology and Laboratory, University of Western Australia Medical School, Western Australia, Australia
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14
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May CC, Cua S, Smetana KS, Powers CJ. Supraprophylactic Anti-Factor Xa Levels Are Associated with Major Bleeding in Neurosurgery Patients Receiving Prophylactic Enoxaparin. World Neurosurg 2021; 157:e357-e363. [PMID: 34655821 DOI: 10.1016/j.wneu.2021.10.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Prior studies demonstrated reduced risk for venous thromboembolism (VTE) in neurosurgical patients secondary to prophylaxis with both heparin and low-molecular-weight heparin. The ability to monitor low-molecular-weight heparin by obtaining anti-factor Xa (anti-Xa) serum levels provides an opportunity to evaluate safety and efficacy. The aim of this study was to describe characteristics of patients who have anti-Xa levels outside of the goal range (0.2-0.4/0.5 IU/mL) and investigate incidence of major bleeding and VTE. METHODS A single-center, retrospective, observational study was conducted on neurosurgical patients receiving enoxaparin for VTE prophylaxis between August 2019 and December 2020. Significance testing was conducted via Fisher exact test and independent samples t test. RESULTS The study included 85 patients. Patients were less likely to have an anti-Xa level in the goal range if they were male, had a higher weight, or were morbidly obese. Three neuroendovascular patients (3.5%) experienced a major bleed. Serum anti-Xa levels were significantly higher in patients who experienced major bleeds compared with patients who did not (0.45 ± 0.16 IU/mL vs. 0.28 ± 0.09 IU/mL, P = 0.003). Patients with a supraprophylactic anti-Xa level (>0.5 IU/mL) were more likely to experience a major bleed (P = 0.005). One VTE event occurred: the patient experienced a pulmonary embolism with anti-Xa level at goal. CONCLUSIONS Anti-Xa-guided enoxaparin dosing for VTE prophylaxis in neurosurgical patients may help prevent major bleeding. These data suggest that a higher anti-Xa level may predispose patients to major bleeding. Further evaluation is needed to identify the goal anti-Xa level for VTE prophylaxis in this population.
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Affiliation(s)
- Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
| | - Santino Cua
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ciarán J Powers
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Pannucci CJ, Fleming KI, Bertolaccini C, Agarwal J, Rockwell WB, Mendenhall SD, Kwok A, Goodwin I, Gociman B, Momeni A. Optimal Dosing of Prophylactic Enoxaparin after Surgical Procedures: Results of the Double-Blind, Randomized, Controlled FIxed or Variable Enoxaparin (FIVE) Trial. Plast Reconstr Surg 2021; 147:947-958. [PMID: 33761517 DOI: 10.1097/prs.0000000000007780] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The accepted "one-size-fits-all" dose strategy for prophylactic enoxaparin may not optimize the medication's risks and benefits after surgical procedures. The authors hypothesized that weight-based administration might improve the pharmacokinetics of prophylactic enoxaparin when compared to fixed-dose administration. METHODS The FIxed or Variable Enoxaparin (FIVE) trial was a randomized, double-blind trial that compared the pharmacokinetic and clinical outcomes of patients assigned randomly to postoperative venous thromboembolism prophylaxis using enoxaparin 40 mg twice daily or enoxaparin 0.5 mg/kg twice daily. Patients were randomized after surgery and received the first enoxaparin dose at 8 hours after surgery. Primary hypotheses were (1) weight-based administration is noninferior to a fixed dose for avoiding underanticoagulation (anti-factor Xa <0.2 IU/ml) and (2) weight-based administration is superior to fixed-dose administration for avoiding overanticoagulation (anti-factor Xa >0.4 IU/ml). Secondary endpoints were 90-day venous thromboembolism and bleeding. RESULTS In total, 295 patients were randomized, with 151 assigned to fixed-dose and 144 to weight-based administration of enoxaparin. For avoidance of under anticoagulation, weight-based administration had a greater effectiveness (79.9 percent versus 76.6 percent); the 3.3 percent (95 percent CI, -7.5 to 12.5 percent) greater effectiveness achieved statistically significant noninferiority relative to the a priori specified -12 percent noninferiority margin (p = 0.004). For avoidance of overanticoagulation, weight-based enoxaparin administration was superior to fixed-dose administration (90.6 percent versus 82.2 percent); the 8.4 percent (95 percent CI, 0.1 to 16.6 percent) greater effectiveness showed significant safety superiority (p = 0.046). Ninety-day venous thromboembolism and major bleeding were not different between fixed-dose and weight-based cohorts (0.66 percent versus 0.69 percent, p = 0.98; 3.3 percent versus 4.2 percent, p = 0.72, respectively). CONCLUSION Weight-based administration showed superior pharmacokinetics for avoidance of underanticoagulation and overanticoagulation in postoperative patients receiving prophylactic enoxaparin. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, I.
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Affiliation(s)
- Christopher J Pannucci
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Kory I Fleming
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Corinne Bertolaccini
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Jayant Agarwal
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - W Bradford Rockwell
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Shaun D Mendenhall
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Alvin Kwok
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Isak Goodwin
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Barbu Gociman
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
| | - Arash Momeni
- From the Divisions of Plastic Surgery and Health Services Research and the Department of Pharmacy Services, University of Utah; Plastic Surgery Northwest; and the Division of Plastic and Reconstructive Surgery, Stanford University
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16
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Ceccato D, Di Vincenzo A, Pagano C, Pesavento R, Prandoni P, Vettor R. Weight-adjusted versus fixed dose heparin thromboprophylaxis in hospitalized obese patients: A systematic review and meta-analysis. Eur J Intern Med 2021; 88:73-80. [PMID: 33888393 DOI: 10.1016/j.ejim.2021.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/01/2021] [Accepted: 03/24/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Fixed dose unfractionated or low molecular weight heparin is the recommended treatment for venous thromboembolism (VTE) prevention in hospitalized patients. However, its efficacy has been questioned in obese population. Results of previous studies on weight-adjusted doses of heparin for VTE prevention are contradictory. Different anticoagulant regimens are used in clinical practice, but their role remains to be elucidated. AIMS To clarify the efficacy and safety of weight-adjusted dose heparin for VTE prevention in obese subjects hospitalized for medical and surgical conditions. METHODS Twelve studies were identified as reporting VTE occurrence, major or minor bleeding and anti-Xa levels. A random-effect meta-analysis was conducted to derive odds ratios (OR) comparing fixed vs weight adjusted-doses heparins on VTE occurrence, bleeding, anti-Xa levels. Medical and surgical patients, prospective vs retrospective and quality of studies were extracted for moderators and meta-regression analysis. RESULTS Weight-adjusted dose heparin administration was not associated with reduced VTE occurrence (6320/13317 patients, OR 1.03, 95% C.I. 0.79 to 1.35), nor increased bleeding (5840/10906 patients, OR 0.84, 95% C.I. 0.65 to 1.08), but it was associated with higher anti-Xa levels (284/294 patients, ES 2.04, 95% C.I. 1.16 to 2.92, p<0.0001). A significant heterogeneity was present for comparison of anti-Xa levels (I2=94%, p=0.0001) but not for VTE occurrence or bleeding (I2=7.6% and 12.8% respectivel). None of the moderators explained the heterogeneity of the results among primary studies. CONCLUSION Weight-adjusted dose as compared to fixed-dose of heparins in the prevention of VTE in obese patients was not associated with a lower risk of VTE nor a higher risk of bleeding.
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Affiliation(s)
- Davide Ceccato
- Department of Internal Medicine, University of Padua, Padua, Italy.
| | | | - Claudio Pagano
- Department of Internal Medicine, University of Padua, Padua, Italy
| | | | - Paolo Prandoni
- Arianna Foundation on Anticoagulation Bologna, Padua, Italy
| | - Roberto Vettor
- Department of Internal Medicine, University of Padua, Padua, Italy
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17
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O'Connor K, Garcia Whitlock AE, Tewksbury C, Williams NN, Dumon KR. Risk factors for postdischarge venous thromboembolism among bariatric surgery patients and the evolving approach to extended thromboprophylaxis with enoxaparin. Surg Obes Relat Dis 2021; 17:1218-1225. [PMID: 33814315 DOI: 10.1016/j.soard.2021.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/09/2021] [Accepted: 02/18/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is one of the most common causes of postoperative mortality following bariatric surgery. The majority of VTE events occur after discharge from the hospital. Little consensus exists regarding who should receive extended enoxaparin thromboprophylaxis or how they should be dosed, namely whether to use weight-based or BMI-stratified dosing strategies. OBJECTIVES Provide an overview of the risk factors associated with VTE in procedures among bariatric patients including the use of predictive tools to stratify risk and the various approaches to enoxaparin chemoprophylaxis in obesity. SETTING Multiple centers. METHODS A review of the literature identified studies evaluating risk factors for VTE including demographic characteristics, co-morbidities, and operative factors. The use of calculators to stratify patients by risk and approaches to extended thromboprophylaxis in obesity were evaluated as well. RESULTS VTE was associated with increased age, weight, male sex, and prior history of VTE, all frequently included in risk calculators. Outside of those major risk factors, there is little consensus about the importance of patient diagnoses. Weight-based dosing was often superior to standardized dosing in studies across disciplines in generating target anti-Xa levels however there is no consistent association of reduced risk of VTE with therapeutic anti-Xa levels. CONCLUSIONS Risk calculators may be a valuable tool for identifying patients at high-risk for VTE, but their efficacy depends on the rating algorithm and inclusion of various risk factors and is methodologically limited by prophylactic interventions. Future work should consider if biochemical factors should be included in patient stratification approaches in particular when defining the ideal chemoprophylaxis approach. Transparency and consistency in data collection and reporting is needed to better assess and inform the ideal dosing strategy to prevent VTE following bariatric surgery.
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Affiliation(s)
- Kathleen O'Connor
- Perelman School of Medicine, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anna E Garcia Whitlock
- Perelman School of Medicine, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen Tewksbury
- Perelman School of Medicine, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Noel N Williams
- Perelman School of Medicine, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristoffel R Dumon
- Perelman School of Medicine, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Rappold JF, Sheppard FR, Carmichael Ii SP, Cuschieri J, Ley E, Rangel E, Seshadri AJ, Michetti CP. Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2021; 6:e000643. [PMID: 33718615 PMCID: PMC7908288 DOI: 10.1136/tsaco-2020-000643] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/27/2021] [Accepted: 02/06/2021] [Indexed: 02/06/2023] Open
Abstract
Venous thromboembolism (VTE) is a potential sequela of injury, surgery, and critical illness. Patients in the Trauma Intensive Care Unit are at risk for this condition, prompting daily discussions during patient care rounds and routine use of mechanical and/or pharmacologic prophylaxis measures. While VTE rightfully garners much attention in clinical patient care and in the medical literature, optimal strategies for VTE prevention are still evolving. Furthermore, trauma and surgical patients often have real or perceived contraindications to prophylaxis that affect the timing of preventive measures and the consistency with which they can be applied. In this Clinical Consensus Document, the American Association for the Surgery of Trauma Critical Care Committee addresses several practical clinical questions pertaining to specific or unique aspects of VTE prophylaxis in critically ill and injured patients.
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Affiliation(s)
| | | | | | - Joseph Cuschieri
- Surgery, University of Washington Seattle Campus, Seattle, Washington, USA
| | - Eric Ley
- Surgery, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Erika Rangel
- Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anupamaa J Seshadri
- Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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19
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Erstad BL, Barletta JF. Drug dosing in the critically ill obese patient: a focus on medications for hemodynamic support and prophylaxis. Crit Care 2021; 25:77. [PMID: 33622380 PMCID: PMC7901103 DOI: 10.1186/s13054-021-03495-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/08/2021] [Indexed: 12/29/2022] Open
Abstract
Medications used for supportive care or prophylaxis constitute a significant portion of drug utilization in the intensive care unit. Evidence-based guidelines are available for many aspects of supportive care but drug doses listed are typically for patients with normal body habitus and not morbid obesity. Failure to account for the pharmacokinetic changes that occur with obesity can lead to an incorrect dose and treatment failure or toxicity. This paper is intended to help clinicians design initial dosing regimens in critically ill obese patients for medications commonly used for hemodynamic support or prophylaxis. A detailed literature search of medications used for supportive care or prophylaxis listed in practice guidelines was conducted with an emphasis on obesity, pharmacokinetics and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided. For medications used for hemodynamic support, a similar strategy can be used as in non-obese patients. Similarly, medications for stress ulcer prophylaxis do not need to be adjusted. Anticoagulants for venous thromboembolism prophylaxis, on the other hand, require an individualized approach where higher doses are necessary.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, 1295 N Martin Ave, PO Box 210202, Tucson, AZ, 85721, USA
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, 19555 N 59th Ave, Glendale, AZ, 85308, USA.
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20
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Gibson CM, Hall C, Davis S, Schillig JM. Comparison of two escalated enoxaparin dosing regimens for venous thromboembolism prophylaxis in obese hospitalized patients. J Thromb Thrombolysis 2021. [PMID: 33400099 DOI: 10.1007/s11239-020-02360-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
Standard fixed-dose enoxaparin dosing regimens may not provide adequate prophylaxis against venous thromboembolism among obese hospitalized patients. While several escalated doses have been shown to result in more frequent attainment of target anti-factor Xa levels than standard doses, few studies compare escalated doses to each other. In this prospective, multi-center trial, enoxaparin 0.5 mg/kg daily (weight-based dosing) and enoxaparin 40 mg twice daily were compared to determine if either dose resulted in more frequent attainment of anti-factor Xa levels within the goal range of 0.2-0.5 IU/mL. Eighty patients with a BMI ≥ 40 kg/m2 were enrolled. There was no difference in the percent of patients achieving goal anti-factor Xa levels (72.5% vs. 70.0%, respectively; p = 0.72). Patients were more likely to attain anti-factor Xa levels below goal range than above. No bleeding or thrombotic events occurred. Either weight-based or twice-daily escalated enoxaparin dosing regimens appear effective at achieving target anti-factor Xa levels among hospitalized patients, and no safety events were noted. Future studies are needed to determine the clinical significance of this result.
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Abstract
Anticoagulants are frequently used as thromboprophylaxis and in patients with atrial fibrillation (AF) or venous thromboembolism (VTE). While obesity rates are reaching epidemic proportions worldwide, the optimal dosage for obese patients has not been established for most anticoagulants, including low-molecular-weight heparin (LMWH), non-vitamin K antagonist oral anticoagulants (NOAC), and pentasaccharides (fondaparinux). The aim of the present systematic review was to summarize the current knowledge and provide recommendations on dosage of LMWH, NOAC, and fondaparinux in obese patients (body mass index [BMI] ≥ 30 kg/m2 or body weight ≥ 100 kg). Based on a systematic search in PubMed and Embase, a total of 72 studies were identified. For thromboprophylaxis with LMWH in bariatric surgery (n = 20 studies), enoxaparin 40 mg twice daily, dalteparin 5,000 IE twice daily, or tinzaparin 75 IU/kg once daily should be considered for patients with BMI ≥ 40 kg/m2. For thromboprophylaxis with LMWH in nonbariatric surgery and in medical inpatients (n = 8 studies), enoxaparin 0.5 mg/kg once or twice daily or tinzaparin 75 IU/kg once daily may be considered in obese patients. For treatment with LMWH (n = 18 studies), a reduced weight-based dose of enoxaparin 0.8 mg/kg twice daily should be considered in patients with BMI ≥ 40 kg/m2, and no dose capping of dalteparin and tinzaparin should be applied for body weight < 140 kg. As regards NOAC, rivaroxaban, apixaban, or dabigatran may be used as thromboprophylaxis in patients with BMI < 40 kg/m2 (n = 4 studies), whereas rivaroxaban and apixaban may be administered to obese patients with VTE or AF, including BMI > 40 kg/m2, at standard fixed-dose (n = 20 studies). The limited available evidence on fondaparinux (n = 3 studies) indicated that the treatment dose should be increased to 10 mg once daily in patients weighing > 100 kg.
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Affiliation(s)
- Anders Abildgaard
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Sofie A Madsen
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark
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22
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Xu A, Sibai H, Atenafu EG, Japs K, Seki JT. Universal venous thromboembolism policy is effective but may not adequately protect hospitalized cancer patients with larger BMI. J Thromb Thrombolysis 2020; 49:113-120. [PMID: 31677148 DOI: 10.1007/s11239-019-01975-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Routine VTE prophylaxis is recommended for hospitalized patients, but its effectiveness and safety in cancer patients is unclear. By observation, larger patients seemed poorly covered by the prophylaxis policy. The effectiveness and safety of VTE prophylaxis policy in the hospitalized patients, their potential risk factors such as BMI were examined. A retrospective chart review was conducted to determine VTE incidences, risk factors for VTE and major bleeding events between 2007 and 2016 on the solid tumor units (STU). Patients were divided into pre-policy (Pre-2012) or post-policy implementation groups (Post-2012). Descriptive statistics were used to evaluate effectiveness and safety of prophylaxis, while propensity score matching (1:3, VTE:Non-VTE) was used to reduce selection bias. The VTE incidence per patient was 1.30% (57/4392) pre-policy and 0.56% (18/3210) post-policy (p value = 0.0013). After propensity score matching, a reduction (32.3%) of VTE cases was observed after policy implementation (OR = 0.677, p = 0.32). BMI was found to be a significant predictor of VTE (OR = 1.094, 95% CI 1.021-1.172, p = 0.011). Between July 2014 and July 2016, 1.7% (19/1091) patients who received anticoagulants had a documented bleeding event. The policy positively impacted VTE events on the STU. A significant predictor of VTE was BMI and patients with high BMI may pose a risk of breaking through standard VTE prophylaxis dosing. There was no reported major bleeding for patients who developed an VTE event despite receiving prophylaxis in either the pre-policy or post-policy phase of the study, although a low incidence of minor bleeding was documented in the post-phase.
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Affiliation(s)
- Anna Xu
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Hassan Sibai
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Jack T Seki
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Department of Pharmacy, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Drake University, Des Moines, IA, USA
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Rosovsky RP, Sanfilippo KM, Wang TF, Rajan SK, Shah S, Martin KA, Ní Áinle F, Huisman M, Hunt BJ, Kahn SR, Kevane B, Lee AYY, McLintock C, Baumann Kreuziger L. Anticoagulation practice patterns in COVID-19: A global survey. Res Pract Thromb Haemost 2020; 4:969-983. [PMID: 32838111 PMCID: PMC7361754 DOI: 10.1002/rth2.12414] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/23/2020] [Accepted: 06/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background Best practice for prevention, diagnosis, and management of venous thromboembolism (VTE) in patients with coronavirus disease 2019 (COVID-19) is unknown due to limited published data in this population. Objectives We aimed to assess current global practice and experience in management of COVID-19-associated coagulopathy to identify information to guide prospective and randomized studies. Methods Physicians were queried about their current approach to prophylaxis, diagnosis, and treatment of VTE in patients with COVID-19 using an online survey tool distributed through multiple international organizations between April 10 and 14, 2020. Results Five hundred fifteen physicians from 41 countries responded. The majority of respondents (78%) recommended prophylactic anticoagulation for all hospitalized patients with COVID-19, with most recommending use of low-molecular-weight heparin or unfractionated heparin. Significant practice variation was found regarding the need for dose escalation of anticoagulation outside the setting of confirmed or suspected VTE. Respondents reported the use of bedside testing when unable to perform standard diagnostic imaging for diagnosis of VTE. Two hundred ninety-one respondents reported observing thrombotic complications in their patients, with 64% noting that the complication was pulmonary embolism. Of the 44% of respondents who estimated incidence of thrombosis in patients with COVID-19 in their hospital, estimates ranged widely from 1% to 50%. One hundred seventy-four respondents noted bleeding complications (34% minor bleeding, 14% clinically relevant nonmajor bleeding, and 12% major bleeding). Conclusion Well-designed epidemiologic studies are urgently needed to understand the incidence and risk factors of VTE and bleeding complications in patients with COVID-19. Randomized clinical trials addressing use of anticoagulation are also needed.
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Affiliation(s)
- Rachel P. Rosovsky
- Department of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Kristen M. Sanfilippo
- Department of MedicineWashington University St. Louis School of Medicine and John Cochran Veterans Administration Medical CenterSt. LouisMOUSA
| | - Tzu Fei Wang
- Department of Internal MedicineOhio State University Wexner Medical CenterColumbusOHUSA
| | - Sandeep K. Rajan
- Department of MedicineUniversity of Nebraska Medical Center College of MedicineMemphisTNUSA
| | - Surbhi Shah
- Department of MedicineUniversity of MinnesotaMinneapolisMNUSA
| | - Karlyn A. Martin
- Department of MedicineNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Fionnuala Ní Áinle
- Department of HematologyMater Misericordiae University Hospital and Rotunda HospitalUniversity College Dublin (UCD) School of MedicineDublinIreland
| | - Menno Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Beverley J. Hunt
- Department of HaematologyKing's CollegePathology & RheumatologyGuy's & St Thomas' NHS Foundation TrustLondonEngland
| | - Susan R. Kahn
- Department of MedicineMcGill UniversityMontrealQCCanada
- Division of Internal Medicine & Center for Clinical EpidemiologyJewish General HospitalMontrealQCCanada
| | - Barry Kevane
- Department of HematologyMater University HospitalUniversity College of Dublin (UCD)School of MedicineDublinIreland
| | - Agnes Y. Y. Lee
- Department of MedicineUniversity of British ColumbiaVancouverBCCanada
| | - Claire McLintock
- National Women's HealthAuckland City HospitalAucklandNew Zealand
| | - Lisa Baumann Kreuziger
- Department of MedicineBlood Research InstituteVersitiMedical College of WisconsinMilwaukeeWIUSA
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Pannucci CJ, Fleming KI, Bertolaccini CB, Prazak AM, Huang LC, Pickron TB. Assessment of Anti-Factor Xa Levels of Patients Undergoing Colorectal Surgery Given Once-Daily Enoxaparin Prophylaxis: A Clinical Study Examining Enoxaparin Pharmacokinetics. JAMA Surg 2020; 154:697-704. [PMID: 31116389 DOI: 10.1001/jamasurg.2019.1165] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Between 4% and 12% of patients undergoing colorectal surgery and receiving enoxaparin, 40 mg per day, have a postoperative venous thromboembolism (VTE) event. An improved understanding of why "breakthrough" VTE events occur despite guideline-compliant prophylaxis is an important patient safety question. Objective To determine the proportion of patients undergoing colorectal surgery who received adequate anticoagulation based on peak anti-factor Xa (aFXa) levels while receiving enoxaparin at 40 mg per day. Design, Setting, and Participants This prospective, nonrandomized clinical trial was conducted between February 2017 and July 2018 with 90-day follow-up at a quaternary academic medical center in the Intermountain West and included patients undergoing colorectal surgery who had surgery after receiving general anesthesia, were admitted for at least 3 days, and received enoxaparin, 40 mg once daily. Interventions All patients had aFXa levels measured after receiving enoxaparin 40 mg per day. Patients whose aFXa level was out of range entered the trial's interventional arm where real-time enoxaparin dose adjustment and repeated aFXa measurement were performed. Main Outcomes and Measures Primary outcome: in-range peak aFXa levels (goal range, 0.3-0.5 IU/mL) with enoxaparin, 40 mg per day. Secondary outcomes: (1) in-range trough aFXa levels (goal range, 0.1-0.2 IU/mL) and (2) the proportion of patients with in-range peak aFXa levels from enoxaparin, 40 mg once daily, vs the real-time enoxaparin dose adjustment protocol. Results Over 16 months, 116 patients undergoing colorectal surgery (65 women [56.0%]; 99 white individuals [85.3%], 13 Hispanic or Latino individuals [11.2%], and 4 Pacific Islander individuals [3.5%]; mean [range] age, 52.1 [18-85] years) were enrolled. Among 106 patients (91.4%) whose peak aFXa level was appropriately drawn, 72 (67.9%) received inadequate anticoagulation (aFXa < 0.3 IU/mL) with enoxaparin, 40 mg per day. Weight and peak aFXa levels were inversely correlated (r2 = 0.38). Forty-seven patients (77%) had a trough aFXa level that was not detectable (ie, most patients had no detectable level of anticoagulation for at least 12 hours per day). Real-time enoxaparin dose adjustment was effective. Patients were significantly more likely to achieve an in-range peak aFXa with real-time dose adjustment as opposed to fixed dosing alone (85.4% vs 29.2%, P < .001). Conclusions and Relevance This study supports the finding that most patients undergoing colorectal surgery receive inadequate prophylaxis from enoxaparin, 40 mg once daily. These findings may explain the high rate of "breakthrough" VTE observed in many clinical trials. Trial Registration ClinicalTrials.gov identifier: NCT02704052.
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Affiliation(s)
- Christopher J Pannucci
- Division of Plastic Surgery, University of Utah, Salt Lake City.,Division of Health Services Research, University of Utah, Salt Lake City
| | - Kory I Fleming
- Division of Plastic Surgery, University of Utah, Salt Lake City
| | | | | | - Lyen C Huang
- Division of General Surgery, University of Utah, Salt Lake City
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Mason SW, Barber A, Jones E, Chen SL, Moll S, Northam K. Safety and Efficacy of High-Dose Unfractionated Heparin Versus High-Dose Enoxaparin for Venous Thromboembolism Prevention in Morbidly Obese Hospitalized Patients. Am J Med 2020; 133:e249-e259. [PMID: 31862336 DOI: 10.1016/j.amjmed.2019.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/15/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Venous thromboembolism is a cause of morbidity and mortality in hospitalized patients, and morbid obesity increases this risk. Various prophylaxis dosing strategies have been investigated. However, it is unclear if high-fixed dose enoxaparin or high-fixed dose unfractionated heparin thromboprophylaxis is optimal for minimizing the incidence of major bleeding and reducing hospital-acquired venous thromboembolism. METHODS A single-center retrospective observational study was conducted in hospitalized patients who were morbidly obese (body mass index ≥40 kg/m2) and who received either high-fixed dose enoxaparin (40 mg every 12 hours) or unfractionated heparin (7500 units every 8 hours) for venous thromboembolism prophylaxis. Co-primary outcomes included incidence of major bleeding and venous thromboembolism diagnosed during hospitalization. Predictors of major bleeding were evaluated by multivariable regression. RESULTS In the 305 patients included (n = 190 unfractionated heparin, n = 115 enoxaparin), the incidence of major bleeding was significantly higher in the unfractionated heparin group (odds ratio [OR] 1.85, 95% confidence interval [CI] 1.07-3.13; P = 0.025), with no significant difference in the incidence of venous thromboembolism diagnosed during hospitalization. The only independent predictors of major bleeding were intensive care acuity (OR 3.32, 95% CI 1.91-5.78; P <0.001) and selection of unfractionated heparin rather than enoxaparin for venous thromboembolism prophylaxis (OR 2.16, 95% CI 1.22-3.82; P = 0.008). CONCLUSION High-fixed dose unfractionated heparin for venous thromboembolism prophylaxis may lead to a higher risk of major bleeding events compared with high-fixed dose enoxaparin in patients who are morbidly obese.
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Affiliation(s)
- S Walker Mason
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill
| | - Alexandra Barber
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill
| | - Emily Jones
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill
| | - Sheh-Li Chen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill
| | - Stephan Moll
- Department of Medicine, Division of Hematology-Oncology, University of North Carolina Medical Center, Chapel Hill
| | - Kalynn Northam
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill.
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Henke PK, Kahn SR, Pannucci CJ, Secemksy EA, Evans NS, Khorana AA, Creager MA, Pradhan AD. Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association. Circulation 2020; 141:e914-e931. [PMID: 32375490 DOI: 10.1161/cir.0000000000000769] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.
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Maurice-Dror C, Litvak M, Keren-Politansky A, Ackerman S, Haim N, Nadir Y. Circulating heparan sulfate chains and body weight contribute to anti-Xa levels in cancer patients using the prophylactic dose of enoxaparin. J Thromb Thrombolysis 2020; 50:112-122. [DOI: 10.1007/s11239-020-02128-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Tromeur C, Le Mao R, Leven C, Couturaud F, Théreaux J, Lacut K. [Diagnostic and therapeutic management of venous thromboembolic disease in obese patients]. Rev Mal Respir 2020; 37:328-340. [PMID: 32284207 DOI: 10.1016/j.rmr.2020.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 08/06/2019] [Indexed: 01/03/2023]
Abstract
Despite the high proportion of obese patients this population remains understudied in the field of venous thromboembolic disease (VTE). Obesity is a risk factor for pulmonary embolism and/or deep vein thrombosis, especially when it is associated with other risk factors for VTE. Currently there is no validated diagnostic algorithm for VTE in the population of obese patients. Moreover, imaging examinations can be of poor quality and inconclusive. In the prevention of VTE, data concerning obese patients are mainly based on low-level studies. Apart from the context of bariatric surgery, an adjustment of heparin doses according to the weight of the patient is proposed only on a case-by-case basis. According to the current guidelines, therapeutic fixed dose oral anticoagulants should not be prescribed for patients with weights exceeding 120kg or a body mass index>40kg/m2. Heparin doses should be weight adjusted and monitored with anti-Xa activity. Anti vitamin K can be prescribed but require INR monitoring. Therefore, new studies specifically dedicated to obese patients are required in the field of VTE for better diagnostic and therapeutic management.
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Affiliation(s)
- C Tromeur
- Département de médecine interne, vasculaire et pneumologie, CHRU, site Cavale-Blanche, Brest, France; EA3878, FCRIN INNOVTE, groupe d'étude thrombose Bretagne Occidentale, Brest, France.
| | - R Le Mao
- Département de médecine interne, vasculaire et pneumologie, CHRU, site Cavale-Blanche, Brest, France; EA3878, FCRIN INNOVTE, groupe d'étude thrombose Bretagne Occidentale, Brest, France
| | - C Leven
- EA3878, FCRIN INNOVTE, groupe d'étude thrombose Bretagne Occidentale, Brest, France; Département de biochimie et pharmaco-toxicologie, CHRU, Brest, France
| | - F Couturaud
- Département de médecine interne, vasculaire et pneumologie, CHRU, site Cavale-Blanche, Brest, France; EA3878, FCRIN INNOVTE, groupe d'étude thrombose Bretagne Occidentale, Brest, France
| | - J Théreaux
- EA3878, FCRIN INNOVTE, groupe d'étude thrombose Bretagne Occidentale, Brest, France; Service de chirurgie viscérale et digestive, CHRU, site Cavale-Blanche, Brest, France
| | - K Lacut
- Département de médecine interne, vasculaire et pneumologie, CHRU, site Cavale-Blanche, Brest, France; EA3878, FCRIN INNOVTE, groupe d'étude thrombose Bretagne Occidentale, Brest, France
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Abstract
Certain patient populations (pregnancy, cancer, renal impairment, and obesity) may be at higher risk of adverse events during low molecular weight heparin (LMWH) therapy and may benefit from anti-Xa monitoring. Yet, evidence supporting a standardized approach to anti-Xa monitoring correlated to clinical outcomes is lacking. Patients with at least one documented anti-Xa level and receiving LMWH within a 6-month period were identified. In a 6-month period, 224 adult LMWH patients with 359 anti-Xa levels were identified. Anti-Xa monitoring was most commonly performed in patients with active cancer receiving venous thromboembolism (VTE) treatment doses (57.4%) or obese patients receiving VTE prophylaxis (48.1%). Anti-Xa monitoring during renal impairment and pregnancy were infrequent (0.9% and 1.8%, respectively). Most (71.9%) anti-Xa levels were therapeutic, but only 45% were drawn correctly in relation to LMWH administration time. Compared to those with therapeutic anti-Xa levels, patients with out-of-range levels were four times as likely to receive a LMWH therapy change (odds ratio, 4.16; 95% confidence interval, 2.53-6.84). However, when levels were supratherapeutic or subtherapeutic, the LMWH doses remained unchanged in one-third to one-half of patients, respectively. Anti-Xa monitoring was most commonly performed in patients with cancer or obesity and was more common with VTE prophylaxis dosing. The majority of levels were therapeutic, indicating that anti-Xa monitoring may be unnecessary even in high-risk patient populations. Many out-of-range anti-Xa levels did not prompt a change in LMWH therapy. Further research is still needed to determine if anti-Xa- guided LMWH dosing improves clinical outcomes.
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Brenner B, Arya R, Beyer-Westendorf J, Douketis J, Hull R, Elalamy I, Imberti D, Zhai Z. Evaluation of unmet clinical needs in prophylaxis and treatment of venous thromboembolism in at-risk patient groups: pregnancy, elderly and obese patients. Thromb J 2019; 17:24. [PMID: 31889915 PMCID: PMC6935082 DOI: 10.1186/s12959-019-0214-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 12/13/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) accounts for an estimated 900,000 cases per year in the US alone and constitutes a considerable burden on healthcare systems across the globe. OBJECTIVE To understand why the burden is so high, qualitative and quantitative research was carried out to gain insights from experts, guidelines and published studies on the unmet clinical needs and therapeutic strategies in VTE prevention and treatment in three populations identified as being at increased risk of VTE and in whom VTE prevention and treatment were regarded as suboptimal: pregnant women, the elderly and obese patients. METHODOLOGY A gap analysis methodology was created to highlight unmet needs in VTE management and to discover the patient populations considered most at risk. A questionnaire was devised to guide qualitative interviews with 44 thrombosis and haemostasis experts, and a review of the literature on VTE in the specific patient groups from 2015 to 2017 was completed. This was followed by a Think Tank meeting where the results from the research were discussed. RESULTS This review highlights the insights gained and examines in detail the unmet needs with regard to VTE risk-assessment tools, biomarkers, patient stratification methods, and anticoagulant and dosing regimens in pregnant women, the elderly and obese patients. CONCLUSIONS Specifically, in pregnant women at high risk of VTE, low-molecular-weight heparin (LMWH) is the therapy of choice, but it remains unclear how to use anticoagulants when VTE risk is intermediate. In elderly patients, evaluation of the benefit of VTE prophylaxis against the bleeding risk is particularly important, and a head-to-head comparison of efficacy and safety of LMWH versus direct oral anticoagulants is needed. Finally, in obese patients, lack of guidance on anticoagulant dose adjustment to body weight has emerged as a major obstacle in effective prophylaxis and treatment of VTE.
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Affiliation(s)
- Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Roopen Arya
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, London, UK
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital ‘Carl Gustav Carus’ Dresden, Dresden, Germany
- King’s Thrombosis Service, Department of Haematology, King’s College London, London, UK
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario Canada
| | - Russell Hull
- Foothills Medical Centre and Thrombosis Research Unit, University of Calgary, Calgary, Canada
| | - Ismail Elalamy
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
- Hematology and Thrombosis Center, Tenon University Hospital, Sorbonne University, INSERM U938, Sorbonne University, Paris, France
| | | | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
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Jones DL, Jones WA, Fleming KI, Higgins TF, Rothberg DL, Zhang Y, Pannucci CJ. Underdosing of Prophylactic Enoxaparin Is Common in Orthopaedic Trauma and Predicts 90-Day Venous Thromboembolism. J Orthop Trauma 2019; 33:570-6. [PMID: 31634287 DOI: 10.1097/BOT.0000000000001563] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the feasibility and impact of real-time anti-factor Xa (aFXa) level monitoring and enoxaparin dose adjustment in orthopaedic trauma. To examine the adequacy of standard fixed-dose enoxaparin chemoprophylaxis and to examine whether patient-specific factors influence enoxaparin metabolism. DESIGN Prospective cohort. SETTING Academic Level-I trauma center. PATIENTS Postoperative adult orthopaedic trauma patients undergoing acute fracture or nonunion surgery of the pelvis, acetabulum, or lower extremity placed on 30 mg of enoxaparin twice daily. INTERVENTION Peak steady-state aFXa levels were drawn with a goal range of 0.2-0.4 IU/mL. Patients with out-of-range levels underwent a 10-mg dose adjustment followed by repeat aFXa draws. MAIN OUTCOME MEASURES Peak and trough aFXa levels, 90-day venous thromboembolism, and bleed events. RESULTS Of 109 enrolled patients, 43% had inadequate initial peak aFXa levels (aFXa < 0.2 IU/mL) with standard dosing. Higher gross weight, acetabular surgery, and operation length predicted low aFXa levels (P < 0.001, 0.006, 0.004, respectively). Dose adjustment increased the proportion of patients with in-range aFXa levels from 53.2% to 87.8% (P < 0.001). Patients with low aFXa levels during hospitalization or at discharge had significantly higher 90-day deep vein thrombosis and pulmonary embolism rates compared to those with adequate aFXa levels (deep vein thrombosis 12% vs. 1.36%; P = 0.023, pulmonary embolism 8% vs. 0%; P = 0.027). There were no major bleed events. CONCLUSIONS Patients receiving inadequate enoxaparin chemoprophylaxis were at significantly increased risk of 90-day venous thromboembolism. Standard fixed-dose enoxaparin provided inadequate chemoprophylaxis in 43% of postoperative orthopaedic trauma patients, which significantly improved with dose adjustment. Weight, acetabular surgery, and operation length predicted inadequate enoxaparin prophylaxis. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Hamadi R, Marlow CF, Nassereddine S, Taher A, Finianos A. Bariatric venous thromboembolism prophylaxis: an update on the literature. Expert Rev Hematol 2019; 12:763-771. [DOI: 10.1080/17474086.2019.1634542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Rachelle Hamadi
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Christina F. Marlow
- Department of Internal Medicine, George Washington University School of Medicine, Washington, D.C., USA
| | - Samah Nassereddine
- Department of Internal Medicine, George Washington University School of Medicine, Washington, D.C., USA
| | - Ali Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Antoine Finianos
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Sherkat Masoum M, Emmerton LM. Enoxaparin for thromboprophylaxis in overweight and obese patients: a prescribing audit at a tertiary hospital. J Pharm Pract Res 2019. [DOI: 10.1002/jppr.1524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Lynne M. Emmerton
- School of Pharmacy and Biomedical Sciences Curtin University Perth Australia
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Dybdahl D, Walliser G, Pershing M, Collins C, Robinson D. Enoxaparin Dosing for Venous Thromboembolism Prophylaxis in Low Body Weight Patients. Clin Med Insights Blood Disord 2019; 12:1179545X19863814. [PMID: 31360075 PMCID: PMC6637836 DOI: 10.1177/1179545x19863814] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 06/18/2019] [Indexed: 12/13/2022]
Abstract
Background: The appropriate dose of enoxaparin for venous thromboembolism (VTE) prophylaxis in low body weight patients is unknown. Objective: The aim of this study is to evaluate the impact of enoxaparin dosing on major and minor bleeding events in low body weight patients. Methods: This was a retrospective cohort study of patients weighing less than 45 kg receiving subcutaneous (SC) enoxaparin for VTE prevention. The primary objective was to determine whether enoxaparin dose was associated with major and minor bleeding. The secondary objective was to determine the incidence of VTE by enoxaparin dose. Results: There were 173 patients included in the study, of which 37 patients received 2 different courses of enoxaparin during hospitalization, resulting in 210 enoxaparin courses. Among all enoxaparin courses, 16.2% were associated with major bleeding and 5.2% with minor bleeding. There was no difference in the incidence of major bleeding by dose (enoxaparin 30 mg SC daily, 30 mg SC twice daily, or 40 mg SC daily; P = .409). Patients who experienced major bleeding were older (54.9 ± 16.1 years) than patients who did not (48.4 ± 18.4 years) (P = .043). There was no difference in the incidence of minor bleeding by dosing schedule (P = .14). No patients experienced a VTE. Conclusion and Relevance: The risk of bleeding was similar by enoxaparin dose but increased with age in low body weight patients. Given the low incidence of VTE in this study, it is reasonable to consider decreasing the prophylactic enoxaparin dose in low body weight patients, especially in the elderly population.
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Affiliation(s)
- Daniel Dybdahl
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, OH, USA
| | - Grant Walliser
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, OH, USA
| | - Michelle Pershing
- Department of Academic Research, OhioHealth Research and Innovation Institute, Columbus, OH, USA
| | - Christy Collins
- Department of Academic Research, OhioHealth Research and Innovation Institute, Columbus, OH, USA
| | - David Robinson
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, OH, USA
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Yam L, Bahjri K, Geslani V, Cotton A, Hong L. Enoxaparin Thromboprophylaxis Dosing and Anti-Factor Xa Levels in Low-Weight Patients. Pharmacotherapy 2019; 39:749-755. [PMID: 31112313 DOI: 10.1002/phar.2295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Enoxaparin is a widely used anticoagulant to prevent venous thromboembolism (VTE). A fixed dose is recommended for VTE prophylaxis. However, fixed prophylactic doses of enoxaparin in low-weight patients may be close to the weight-based dosing recommended for VTE treatment. OBJECTIVE To evaluate peak anti-factor Xa (aFXa) levels in low-weight patients receiving enoxaparin for VTE prophylaxis. METHODS Retrospective cohort of adult patients weighing < 55 kg who were hospitalized at Loma Linda University Medical Center between January 2008 and February 2017. All patients received enoxaparin for VTE prophylaxis with a peak aFXa level drawn. The primary endpoint was the proportion of patients achieving peak aFXa levels within the goal range of 0.2-0.5 unit/ml. RESULTS Of 35 patients receiving enoxaparin for VTE prophylaxis with an appropriately timed peak aFXa level, 74% achieved goal peak aFXa levels and the median daily dose of enoxaparin was 30 mg. The mean weight was approximately 44 kg. No significant correlations between aFXa level and body mass index or body weight were found. CONCLUSION A lower dose of enoxaparin may be reasonable in low-weight patients for VTE prophylaxis. There appears to be no safety concerns with reduced enoxaparin dosing in low-weight patients. More robust data are needed to confirm these findings.
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Affiliation(s)
- Lily Yam
- PIH Health Hospital Downey, Downey, California
| | - Khaled Bahjri
- School of Pharmacy, Loma Linda University, Loma Linda, California
| | - Van Geslani
- School of Medicine, Loma Linda University, Loma Linda, California
| | - Adrian Cotton
- Loma Linda University Medical Center, Loma Linda, California
| | - Lisa Hong
- School of Pharmacy, Loma Linda University, Loma Linda, California
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Brunetti L, Wassef A, Sadek R, Deshpande K, Ziegler J, Na SS, Riley P, Kagan L. Anticoagulant activity of enoxaparin and unfractionated heparin for venous thromboembolism prophylaxis in obese patients undergoing sleeve gastrectomy. Surg Obes Relat Dis 2019; 15:363-373. [DOI: 10.1016/j.soard.2018.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/02/2018] [Accepted: 12/12/2018] [Indexed: 12/27/2022]
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Lewis TC, Cortes J, Altshuler D, Papadopoulos J. Venous Thromboembolism Prophylaxis: A Narrative Review With a Focus on the High-Risk Critically Ill Patient. J Intensive Care Med 2018; 34:877-888. [PMID: 30165770 DOI: 10.1177/0885066618796486] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Venous thromboembolism (VTE) is a major health concern associated with significant morbidity and mortality. Critically ill patients are at an increased risk of VTE compared to general medical patients due to unique risk factors: prolonged immobilization, invasive lines and devices, certain medications, and acquired thrombophilia. Furthermore, VTE in the critically ill is associated with increased duration of mechanical ventilation, increased length of intensive care unit and hospital stay, and a trend toward increased mortality. Clinical practice guidelines therefore recommend VTE prophylaxis with either subcutaneous heparin or low-molecular-weight heparin for all critically ill patients without contraindication. Yet, many patients will develop VTE despite appropriate pharmacologic prophylaxis, which has led to interest in risk-stratifying critically ill patients for more aggressive prophylaxis strategies. Recent research identified patients at highest risk of failure of thromboprophylaxis and provided insight into the pathophysiologic mechanisms. Obesity and the receipt of vasopressors are 2 risk factors consistently identified in observational studies; further clinical data support decreased absorption of anticoagulant administered via the subcutaneous route as the likely mechanism behind thromboprophylaxis failure in these patient populations. Several studies have investigated novel thromboprophylaxis strategies to circumvent pharmacokinetic limitations in patients who are obese or on vasopressors: increased fixed-dose, weight-based subcutaneous, or continuous intravenous infusion of a prophylactic dose of anticoagulant has shown promise in limited studies; however, the results have yet to demonstrate superiority compared to current standard-of-care. This review discusses observational studies identifying patients at risk of thromboprophylaxis failure and critiques clinical studies evaluating novel thromboprophylaxis strategies in high-risk, critically ill patients with a focus on their limitations. Future studies are currently being conducted that will provide further guidance into the appropriate use of individualized thromboprophylaxis.
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Affiliation(s)
- Tyler C Lewis
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Jennifer Cortes
- Department of Pharmacy Services, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Diana Altshuler
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
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Abstract
OBJECTIVES To evaluate the degree of anticoagulation achieved with different enoxaparin dosing regimens used in obese and morbidly obese patients in a hospital setting in Jordan. METHODS All obese adult patients who were prescribed enoxaparin for various indications were invited to participate in the study. The anti-factor Xa (anti-Xa) level was checked once after 4-6 hours of the third or fourth dose of enoxaparin (at steady state). Patients were followed daily to evaluate drug efficacy and safety through their hospital course. RESULTS Enoxaparin daily dose used for prophylaxis indications ranged from 0.3 to 0.85 mg/kg and from 0.31 to 2.25 mg/kg in case of certain treatment indications. Most participants who received enoxaparin for treatment indications (76.9%) were on capping dosing regimens, which was <1 mg/kg twice daily. On the other hand, most patients (88.5%) who received enoxaparin for prophylaxis indications were on a fixed 40 mg/d dose. Among the 52 patients who completed the study, 19 patients (36.5%) had therapeutic anti-Xa levels. The results showed no statistically significant associations between regimens that were used and achieving therapeutic anti-Xa level (p>0.05). No bleeding events or thrombocytopenia were noticed, and there was one case of recurrent thrombosis. CONCLUSION Enoxaparin dosing regimens that were used for obese patients varied based on prescribing physicians. Regardless of the regimen used, the majority of participants had nontherapeutic anti-Xa. Individualized dosing regimens based on anti-Xa levels are warranted for obese patients on enoxaparin.
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Affiliation(s)
- Linda Tahaineh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Sahar M Edaily
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology (JUST), Irbid, Jordan
| | - Shadi F Gharaibeh
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Jerash University, Jerash, Jordan
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Rocca B, Fox KAA, Ajjan RA, Andreotti F, Baigent C, Collet JP, Grove EL, Halvorsen S, Huber K, Morais J, Patrono C, Rubboli A, Seljeflot I, Sibbing D, Siegbahn A, Ten Berg J, Vilahur G, Verheugt FWA, Wallentin L, Weiss TW, Wojta J, Storey RF. Antithrombotic therapy and body mass: an expert position paper of the ESC Working Group on Thrombosis. Eur Heart J 2018; 39:1672-1686f. [PMID: 29509886 DOI: 10.1093/eurheartj/ehy066] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 02/11/2024] Open
Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, UK
| | - Ramzi A Ajjan
- Leeds Institute for Cardiovascular and Metabolic Medicine, the LIGHT Laboratories, University of Leeds, Leeds LS2?9JT, UK
| | - Felicita Andreotti
- Cardiovascular Department, Catholic University Hospital, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Jean-Philippe Collet
- Institute of Cardiology, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne Université Paris 06 (UPMC), ACTION Study Group, INSERM UMR_S 1166, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Bd de l'hopital, 75013 Paris, France
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus; Denmark
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - João Morais
- Division of Cardiology, Leiria Hospital Center, R. de Santo André, 2410-197 Leiria, Portugal
| | - Carlo Patrono
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Largo Nigrisoli 2, 40133 Bologna, Italy
| | - Ingebjorg Seljeflot
- Department of Cardiology, Center for Clinical Heart Research, Oslo University Hospital Ullevål and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Dirk Sibbing
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-Universität, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Marchioninistrasse 15, 81377 Munich, Germany
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, 751 85 Uppsala, Sweden
| | - Jurrien Ten Berg
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC, IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Avda. S. Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University & Uppsala Clinical Research Center, Uppsala Science Park, MTC, Dag Hammarskjölds väg 14B, SE-752 37 Uppsala, Sweden
| | - Thomas W Weiss
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Medical University Vienna, Vienna, Austria
- Core Facilities, Medical University Vienna, Vienna, Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
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Abstract
OBJECTIVE To review the literature on both thromboprophylaxis and treatment of venous thromboembolism (VTE) with enoxaparin in low- and high-body-weight patients and to make dosing and monitoring recommendations in these patient populations. DATA SOURCES A search using PubMed was conducted (1995 to January 2018) using the following key words: enoxaparin, body weight, AND thromboprophylaxis, or AND treatment. Additional references were identified from a review of citations. STUDY SELECTION AND DATA EXTRACTION Studies included examined the effect of body weight and/or body mass index (BMI) on VTE, bleeding, enoxaparin dosing, and/or anti-Xa concentrations for thromboprophylaxis and treatment-dose enoxaparin. Studies in pediatric and pregnant patients were excluded. DATA SYNTHESIS Optimal enoxaparin dosing strategies for VTE prophylaxis and treatment for patients at extremes of weight have not yet been elucidated by clinical trials; however, data suggest that standard dosing regimens may not be appropriate in these patients. Relevance to Patient Care and Clinical Practice: This review provides a thorough discussion on both thromboprophylaxis and treatment of VTE with enoxaparin in low- and high-body-weight patients. It includes dosing recommendations to guide clinicians caring for these patient populations. CONCLUSIONS Patients at extremes of weight require special consideration to determine appropriate enoxaparin doses. Specifically, low-body-weight patients may benefit from 30 mg subcutaneously daily for VTE prophylaxis, and standard weight-based dosing for VTE treatment. Conversely, in patients with BMIs ≥40 kg/m2, 40 mg subcutaneously twice daily is recommended, with consideration for higher doses in patients with BMIs ≥50 kg/m2.
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Affiliation(s)
| | - Kelly Covert
- 2 Bill Gatton College of Pharmacy, Johnson City, TN, USA
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Samuel D, Gressel GM, Isani S, Novetsky AP, Nevadunsky NS. Saddle pulmonary embolus resulting in cardiovascular collapse requiring extracorporeal membrane oxygenation in a postoperative patient with endometrial cancer. Gynecol Oncol Rep 2018; 24:36-38. [PMID: 29915795 PMCID: PMC6003405 DOI: 10.1016/j.gore.2018.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 03/13/2018] [Accepted: 03/14/2018] [Indexed: 11/05/2022] Open
Abstract
Background Venous thromboembolism after open gynecologic surgery is not uncommon, especially in the presence of other risk factors such as obesity, prolonged surgical time or gynecologic malignancy. Case We present the case of a 62 y.o. patient who underwent open hysterectomy and surgical staging for uterine serous carcinoma. She was readmitted with lower extremity edema. During her workup, she underwent cardiovascular arrest secondary to saddle pulmonary embolus requiring cardiopulmonary resuscitation and extracorporeal membrane oxygenation. After systemic and catheter directed thrombolysis, and a long hospitalization, she was discharged home in stable condition. Conclusion Saddle pulmonary embolus is a potentially catastrophic and fatal postoperative complication. This case demonstrates a successful implementation of directed thrombolysis, veno-arterial extracorporeal membrane oxygenation and multidisciplinary management in a case of postoperative saddle pulmonary embolus. Précis We report a case of an endometrial cancer patient who sustained a massive postoperative pulmonary embolus and was successfully resuscitated using extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation can help stabilize patients with massive embolus. Catheter directed alteplase may reduce risk of bleeding compared to systemic therapy. A multidisciplinary approach to massive saddle embolus may improve patient outcomes.
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Affiliation(s)
- David Samuel
- Montefiore Medical Center and Albert Einstein College of Medicine, Department of Obstetrics & Gynecology and Women's Health, 1825 Eastchester Road, Room 722. Bronx, NY 10463, United States
| | - Gregory M Gressel
- Montefiore Medical Center and Albert Einstein College of Medicine, Department of Obstetrics & Gynecology and Women's Health, 1825 Eastchester Road, Room 722. Bronx, NY 10463, United States.,Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Sara Isani
- Montefiore Medical Center and Albert Einstein College of Medicine, Department of Obstetrics & Gynecology and Women's Health, 1825 Eastchester Road, Room 722. Bronx, NY 10463, United States.,Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Akiva P Novetsky
- Montefiore Medical Center and Albert Einstein College of Medicine, Department of Obstetrics & Gynecology and Women's Health, 1825 Eastchester Road, Room 722. Bronx, NY 10463, United States.,Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Nicole S Nevadunsky
- Montefiore Medical Center and Albert Einstein College of Medicine, Department of Obstetrics & Gynecology and Women's Health, 1825 Eastchester Road, Room 722. Bronx, NY 10463, United States.,Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, United States
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Venclauskas L, Maleckas A, Arcelus JI. European guidelines on perioperative venous thromboembolism prophylaxis: Surgery in the obese patient. Eur J Anaesthesiol 2018; 35:147-53. [DOI: 10.1097/eja.0000000000000703] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Elalamy I, Falanga A. Meeting Report EuroG20 Meeting on Cancer-Associated Thrombosis (CAT) Bergamo, Italy 7 April 2016. Cancer Invest 2018; 36:73-91. [PMID: 29420084 DOI: 10.1080/07357907.2018.1425698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The EuroG20 meeting on cancer-associated thrombosis (CAT) convened in Bergamo, Italy on 7 April 2016 to discuss a selection of controversial topics in CAT management. This satellite meeting besides ICTHIC in Bergamo has the objective to propose an European Guidance on CAT in various complex situations where evidence-based guidelines are lacking, driven by eminence-based thoughts of 20 experts and key opinion leaders in thrombosis from EU area and 8 experts from the rest of the world.
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Affiliation(s)
- I Elalamy
- a Biological Hematology Department, Hôpital TENON APHP Hôpitaux Universitaires de l'Est Parisien , INSERM UMRS 938 Sorbonne Université , Paris , France
| | - A Falanga
- b Department of Immunohematology and Transfusion Medicine & the Hemostasis and Thrombosis Center , Hospital Papa Giovanni XXIII , Piazza OMS , Bergamo , Italy
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Pannucci CJ, Hunt MM, Fleming KI, Prazak AM. Weight-Based Dosing for Once-Daily Enoxaparin Cannot Provide Adequate Anticoagulation for Venous Thromboembolism Prophylaxis. Plast Reconstr Surg 2017; 140:815-22. [PMID: 28953735 DOI: 10.1097/PRS.0000000000003692] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgeons commonly provide enoxaparin prophylaxis to high-risk patients to decrease venous thromboembolism risk. The authors' prior work demonstrated that most patients receive inadequate venous thromboembolism prophylaxis, based on anti-factor Xa level, when enoxaparin 40 mg/day is provided and that peak anti-factor Xa level correlates with weight. This study models a weight-based strategy for daily enoxaparin prophylaxis and its impact on anti-factor Xa levels. METHODS The authors enrolled plastic surgery patients who received enoxaparin 40 mg/day and had anti-factor Xa levels drawn. The enoxaparin dose of 40 mg was converted to a milligram-per-kilogram dose for each patient. Stratified analysis examined the milligram-per-kilogram dose that produced low, in-range, and high anti-factor Xa levels to identify the appropriate milligram-per-kilogram dose to optimize venous thromboembolism prevention and bleeding events. RESULTS Among 94 patients, weight-based dosing ranged from 0.28 to 0.94 mg/kg once daily. For peak and trough anti-factor Xa levels, there was nearly complete overlap for milligram-per-kilogram dosing that produced low versus in-range anti-factor Xa levels. For peak anti-factor Xa, there was nearly complete overlap for milligram-per-kilogram dosing that produced in-range versus high anti-factor Xa levels. Mean milligram-per-kilogram dose was not significantly different between patients who did or did not have postoperative venous thromboembolism (0.41 mg/kg versus 0.52 mg/kg; p = 0.085) or clinically relevant bleeding (0.48 mg/kg versus 0.51 mg/kg; p = 0.73). CONCLUSIONS Alterations in enoxaparin dose magnitude based on patient weight cannot allow a high proportion of patients to achieve appropriate anti-factor Xa levels when once-daily enoxaparin prophylaxis is provided. Future research should examine the impact of increased enoxaparin dose frequency on anti-factor Xa levels, venous thromboembolism events, and bleeding. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Gelikas S, Eldar SM, Lahat G. Anti-factor Xa levels in patients undergoing laparoscopic sleeve gastrectomy: 2 different dosing regimens of enoxaparin. Surg Obes Relat Dis 2017; 13:1753-1759. [DOI: 10.1016/j.soard.2017.07.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 06/27/2017] [Accepted: 06/20/2017] [Indexed: 01/06/2023]
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Wall V, Fleming KI, Tonna JE, Nunez J, Lonardo N, Shipley RW, Nirula R, Pannucci CJ. Anti-Factor Xa measurements in acute care surgery patients to examine enoxaparin dose. Am J Surg 2017; 216:222-229. [PMID: 28736059 DOI: 10.1016/j.amjsurg.2017.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND The purpose of this study was to determine if fixed dose enoxaparin prophylaxis provided effective anticoagulation for acute care surgery patients and to examine whether a real-time enoxaparin dose adjustment algorithm optimized anticoagulation. METHODS Acute care surgical patients placed on enoxaparin prophylaxis 30 mg twice daily were recruited prospectively. Peak steady state aFXa levels were drawn with a goal peak aFXa range of 0.2-0.4 IU/ml. A real time dose adjustment algorithm was implemented for patients with out-of-range levels. RESULTS Fifty five patients were included. 56.4% of patients had low aFXa levels (<0.2 IU/mL). Real-time enoxaparin dose adjustment significantly increased the proportion of patients who achieved in-range peak aFXa levels, compared to standard dosing (74.5% vs 41.8%, p < 0.001). Patients with initial inadequate peak aFXa levels had a higher rate of 90-day post-operative VTE, although not statistically significant (16.1% vs. 8.3%, p = 0.50). CONCLUSION The majority of acute care surgery patients receive inadequate VTE prophylaxis with fixed enoxaparin dosing.
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Affiliation(s)
- Vanessa Wall
- School of Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Kory I Fleming
- Division of Plastic Surgery, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States; Critical Care, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States; Division of Emergency Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Jade Nunez
- Division of General Surgery, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Nick Lonardo
- Department of Pharmacy Services, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - R Wayne Shipley
- Department of Pharmacy Services, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Ram Nirula
- Division of General Surgery, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
| | - Christopher J Pannucci
- Division of Plastic Surgery, Division of Health Services Research, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, United States.
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Miranda S, Le Cam-Duchez V, Benichou J, Donnadieu N, Barbay V, Le Besnerais M, Delmas FX, Cuvelier A, Lévesque H, Benhamou Y, Armengol G. Adjusted value of thromboprophylaxis in hospitalized obese patients: A comparative study of two regimens of enoxaparin: The ITOHENOX study. Thromb Res 2017; 155:1-5. [PMID: 28460259 DOI: 10.1016/j.thromres.2017.04.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 04/03/2017] [Accepted: 04/09/2017] [Indexed: 01/14/2023]
Abstract
Thromboprophylaxis is a mainstay of hospital care in patients at high risk of thrombosis. Fixed doses of low-molecular-weight heparin (LMWH) are recommended for thromboprophylaxis in patients admitted to hospital for an acute medical condition. However, the distribution of LMWH is weight-based, and the efficacy of standard doses in obese patients may be decreased. Data for obese patients are mainly available in bariatric surgery with extremely obese patients who are at greater risk of venous thromboembolism than those hospitalized for a medical condition. We conducted a randomized control trial in medically obese inpatients (BMI≥30kg/m2) assessing two regimens of enoxaparin (40mg and 60mg SQ daily) in order to determine whether a stronger dosage would achieve higher anti-Xa level suitable for thromboprophylaxis. Between September 2013 and April 2015, 91 patients were included in the study (mean (±standard deviation) age was 70.4±10.7years, average BMI 37.8±6.4kg/m2). Main indications of thromboprophylaxis were mainly acute infection (50%), acute respiratory failure (10%), acute congestive heart failure (9%) and acute rheumatic disorders (18%). Average anti-Xa activity, measured 4h after the third administration of enoxaparin was 0.25±0.09IU/mL in group 1 (enoxaparin 40mg) and 0.35±0.13IU/mL in group 2 (enoxaparin 60mg) (P<10-3). The proportions of patients with normal anti-Xa activity (between 0.32 and 0.54IU/mL) were 31% (n=11) and 69% (n=24) in group 1 and 2 respectively (P=0.007). The proportions of anti-Xa activity measurement below the normal range were 64% and 36% in group 1 and 2 (P<10-3) respectively. Subgroup analysis focusing on high weight patients (above 100kg, n=45) showed a marked difference in the proportion of patients with normal anti-Xa activity between group 1 (9%) and 2 (44%) (P=0.009). No venous thromboembolism occurred during the study and one patient in group 1 died because of hemorrhagic shock due to a gastric ulcer. Incidence of adverse events was not different between the two groups (P=0.52). In conclusion, the ITOHENOX study shows in medically obese inpatients that thromboprophylaxis with enoxaparin 60mg provides higher control of anti-Xa activity, without more bleeding complications than the standard enoxaparin regimen. This trial is registered with ClinicalTrials.gov, number NCT01707732.
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Affiliation(s)
- Sébastien Miranda
- Department of internal medicine, vascular and thrombosis unit, Rouen University Hospital, Rouen, France; INSERM U1096, Rouen University, Rouen, France
| | - Véronique Le Cam-Duchez
- INSERM U1096, Rouen University, Rouen, France; Vascular Hemostasis Unit, Rouen University Hospital, Rouen, France
| | - Jacques Benichou
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Nathalie Donnadieu
- Pharmacy, Unit of Clinical Trials, Rouen University Hospital, Rouen, France
| | - Virginie Barbay
- Vascular Hemostasis Unit, Rouen University Hospital, Rouen, France
| | - Maelle Le Besnerais
- Department of internal medicine, vascular and thrombosis unit, Rouen University Hospital, Rouen, France
| | | | - Antoine Cuvelier
- Pulmonary & Respiratory Intensive Care Department, UPRES EA 3830, Rouen University Hospital, Rouen, France
| | - Hervé Lévesque
- Department of internal medicine, vascular and thrombosis unit, Rouen University Hospital, Rouen, France; INSERM U1096, Rouen University, Rouen, France
| | - Ygal Benhamou
- Department of internal medicine, vascular and thrombosis unit, Rouen University Hospital, Rouen, France; INSERM U1096, Rouen University, Rouen, France
| | - Guillaume Armengol
- Department of internal medicine, vascular and thrombosis unit, Rouen University Hospital, Rouen, France.
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50
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He Z, Morrissey H, Ball P. Review of current evidence available for guiding optimal Enoxaparin prophylactic dosing strategies in obese patients-Actual Weight-based vs Fixed. Crit Rev Oncol Hematol 2017; 113:191-4. [PMID: 28427508 DOI: 10.1016/j.critrevonc.2017.03.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 02/24/2017] [Accepted: 03/20/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The current debate over the optimal Enoxaparin prophylactic dosing strategies in obese patients centre around whether it should be based on the actual weight of the patient (i.e. weight-based), or at an artificially fixed amount, as it is the case in Australia (40mg daily). The vast majority of the evidence available today is laboratory-based, measuring serum Antifactor-Xa activities as a marker for physiological response. AIM The aim of the parent study is to compare the clinical outcomes for obese patients who received fixed doses of enoxaparin compared to those who received weight-based doses within the licensed dosage recommendations. This review was conducted to examine whether a gap in knowledge exists in relation to dosing obese patients with enoxaparin as VTE prophylaxis after hospital admission to aid in development of the parent study concept. METHOD Databases such as Medline, EBSCOhost, ProQuest were interrogated using combinations of words such as "enoxaparin", AND "dosing strategy", AND "obese/obesity" AND "prophylaxis". Only eleven out of 14 primary studies which were considered to be sufficiently similar in methodology and anticipated outcomes were reviewed and analysed. RESULTS Pooled data from the eleven studies suggested that weight-based or higher-than-fixed dosing had a 36.2% higher success rate than fixed dosing, and was more likely to achieve the desired serum Anti-Xa activity levels (52.2% and 16% respectively). The rate of failure to achieve this is significantly lower in the weight-based groups (13.3%) than in fixed-dose groups (18.5%). These eleven studies reviewed included 601 patients in total. CONCLUSION There is insufficient evidence to support or negate the current enoxaparin health outcomes in obese and very obese patients due to the lack of post-discharge follow-up from hospitals. Further research is required to compare long-term outcomes after fixed and weight-based dosing of enoxaparin. The optimal dose of enoxaparin per kilogram of body weight for prophylaxis remains to be determined.
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