Structured benefit-risk assessment for enoxaparin, in the context of its label extension, for the extended treatment of deep vein thrombosis and pulmonary embolism, and prevention of its recurrence in patients with active cancer

PURPOSE

Guidelines recommend low-molecular-weight heparins (LMWHs) for patients with cancer-associated thrombosis. However, until recently, only dalteparin and tinzaparin were approved in the European Economic Area (EEA) for these patients. This study compares the benefit-risk profile of enoxaparin with dalteparin and tinzaparin for the extended treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrence in adult patients with active cancer.

METHODS

A semi-quantitative structured benefit-risk assessment was conducted for the label-extension application of enoxaparin based on the benefit-risk action team descriptive framework: define decision context; determine key benefit and risk outcomes; identify data sources; extract data; interpret results.

RESULTS

The key benefits were defined as reduced all-cause mortality and venous thromboembolism (VTE) recurrence (including symptomatic DVT, fatal PE or non-fatal PE); the key risks were major and non-major bleeding of clinical significance, and heparin-induced thrombocytopenia (HIT). Enoxaparin demonstrated comparable effects for the reduction of VTE recurrence and all-cause mortality versus other EEA-approved LMWHs (dalteparin, tinzaparin). There was no evidence of a significant difference between enoxaparin and the comparator groups with regard to incidence of major and non-major bleeding. The data on HIT were too limited to assess the difference between the two groups.

CONCLUSIONS

The assessment demonstrated a favourable benefit-risk profile for enoxaparin similar to that of other EEA-approved LMWHs for the treatment of DVT and PE and the prevention of recurrence in patients with active cancer and thus supported the label-extension approval.

Impact of perioperative low-molecular-weight heparin therapy on clinical events of elderly patients with prior coronary stents implanted > 12 months undergoing non-cardiac surgery: a randomized, placebo-controlled trial

BACKGROUND

Little is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12 months undergoing non-cardiac surgery. This randomized trial was designed to compare the clinical benefits and risks of antiplatelet drug discontinuation via LMWH bridging therapy.

METHODS

Patients were randomized 1:1 to receive subcutaneous injections of either dalteparin sodium or placebo. The primary efficacy endpoint was cardiac or cerebrovascular events. The primary safety endpoint was major bleeding.

RESULTS

Among 2476 randomized patients, the variables (sex, age, body mass index, comorbidities, medications, and procedural characteristics) and percutaneous coronary intervention information were not significantly different between the bridging and non-bridging groups. During the follow-up period, the rate of the combined endpoint in the bridging group was significantly lower than in the non-bridging group (5.79% vs. 8.42%, p = 0.012). The incidence of myocardial injury in the bridging group was significantly lower than in the non-bridging group (3.14% vs. 5.19%, p = 0.011). Deep vein thrombosis occurred more frequently in the non-bridging group (1.21% vs. 0.4%, p = 0.024), and there was a trend toward a higher rate of pulmonary embolism (0.32% vs. 0.08%, p = 0.177). There was no significant difference between the groups in the rates of acute myocardial infarction (0.81% vs. 1.38%), cardiac death (0.24% vs. 0.41%), stroke (0.16% vs. 0.24%), or major bleeding (1.22% vs. 1.45%). Multivariable analysis showed that LMWH bridging, creatinine clearance < 30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus were independent predictors of ischemic events. LMWH bridging and a preoperative platelet count of < 70 × 109/L were independent predictors of minor bleeding events.

CONCLUSIONS

This study showed the safety and efficacy of perioperative LMWH bridging therapy in elderly patients with coronary stents implanted > 12 months undergoing non-cardiac surgery. An alternative approach might be the use of bridging therapy with half-dose LMWH.

TRIAL REGISTRATION

ISRCTN65203415.

Postoperative low molecular weight heparin bridging treatment for patients at high risk of arterial thromboembolism (PERIOP2): double blind randomised controlled trial

OBJECTIVE

To determine the efficacy and safety of dalteparin postoperative bridging treatment versus placebo for patients with atrial fibrillation or mechanical heart valves when warfarin is temporarily interrupted for a planned procedure.

DESIGN

Prospective, double blind, randomised controlled trial.

SETTING

10 thrombosis research sites in Canada and India between February 2007 and March 2016.

PARTICIPANTS

1471 patients aged 18 years or older with atrial fibrillation or mechanical heart valves who required temporary interruption of warfarin for a procedure.

INTERVENTION

Random assignment to dalteparin (n=821; one patient withdrew consent immediately after randomisation) or placebo (n=650) after the procedure.

MAIN OUTCOME MEASURES

Major thromboembolism (stroke, transient ischaemic attack, proximal deep vein thrombosis, pulmonary embolism, myocardial infarction, peripheral embolism, or vascular death) and major bleeding according to the International Society on Thrombosis and Haemostasis criteria within 90 days of the procedure.

RESULTS

The rate of major thromboembolism within 90 days was 1.2% (eight events in 650 patients) for placebo and 1.0% (eight events in 820 patients) for dalteparin (P=0.64, risk difference -0.3%, 95% confidence interval -1.3 to 0.8). The rate of major bleeding was 2.0% (13 events in 650 patients) for placebo and 1.3% (11 events in 820 patients) for dalteparin (P=0.32, risk difference -0.7, 95% confidence interval -2.0 to 0.7). The results were consistent for the atrial fibrillation and mechanical heart valves groups.

CONCLUSIONS

In patients with atrial fibrillation or mechanical heart valves who had warfarin interrupted for a procedure, no significant benefit was found for postoperative dalteparin bridging to prevent major thromboembolism.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00432796.

Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer

BACKGROUND

Recent guidelines recommend consideration of the use of oral edoxaban or rivaroxaban for the treatment of venous thromboembolism in patients with cancer. However, the benefit of these oral agents is limited by the increased risk of bleeding associated with their use.

METHODS

This was a multinational, randomized, investigator-initiated, open-label, noninferiority trial with blinded central outcome adjudication. We randomly assigned consecutive patients with cancer who had symptomatic or incidental acute proximal deep-vein thrombosis or pulmonary embolism to receive oral apixaban (at a dose of 10 mg twice daily for the first 7 days, followed by 5 mg twice daily) or subcutaneous dalteparin (at a dose of 200 IU per kilogram of body weight once daily for the first month, followed by 150 IU per kilogram once daily). The treatments were administered for 6 months. The primary outcome was objectively confirmed recurrent venous thromboembolism during the trial period. The principal safety outcome was major bleeding.

RESULTS

Recurrent venous thromboembolism occurred in 32 of 576 patients (5.6%) in the apixaban group and in 46 of 579 patients (7.9%) in the dalteparin group (hazard ratio, 0.63; 95% confidence interval [CI], 0.37 to 1.07; P<0.001 for noninferiority). Major bleeding occurred in 22 patients (3.8%) in the apixaban group and in 23 patients (4.0%) in the dalteparin group (hazard ratio, 0.82; 95% CI, 0.40 to 1.69; P = 0.60).

CONCLUSIONS

Oral apixaban was noninferior to subcutaneous dalteparin for the treatment of cancer-associated venous thromboembolism without an increased risk of major bleeding. (Funded by the Bristol-Myers Squibb-Pfizer Alliance; Caravaggio ClinicalTrials.gov number, NCT03045406.).

[Direct oral anticoagulants in the treatment of cancer-associated thrombosis]

The use of direct oral anticoagulants (DOACs) has been largely -implemented in the management of venous thromboembolic disease in non-cancer patients. In cancer-associated thrombosis, low molecular weight heparins (LMWHs) and especially dalteparin have long been the reference standard therapy. Following the publication of two randomised trials comparing edoxaban and rivaroxaban to -dalteparin, DOACs now represent an alternative with an interesting efficacy and safety profile. Moreover, they offer the comfort of an oral administration and a lower cost. In patients with gastrointestinal or genitourinary cancers however, a higher bleeding risk has been shown with DOACs. LMWHs thus remain the treatment of choice in this group of patients.

Extended treatment with edoxaban in cancer patients with venous thromboembolism: A post-hoc analysis of the Hokusai-VTE Cancer study

BACKGROUND

Patients with active cancer and venous thromboembolism (VTE) are at high risk of recurrence. Therefore, continued anticoagulant therapy beyond the initial 6 months is suggested in this patient population, but evidence supporting this approach is limited.

METHODS

The Hokusai VTE Cancer trial compared edoxaban with dalteparin for VTE treatment in patients with active cancer. This post hoc analysis focused on the follow-up period from 6 to 12 months. The primary outcome was the composite of adjudicated first recurrent VTE or major bleeding. Secondary outcomes included recurrent VTE, major bleeding, and clinically relevant bleeding.

RESULTS

Of the 522 and 524 patients randomized to edoxaban or dalteparin, 294 (56%) received edoxaban and 273 (52%) received dalteparin for more than 6 months (median duration of 318 and 211 days, respectively). Between 6 and 12 months, the primary outcome during study treatment occurred in seven patients (2.4%) in the edoxaban group and six patients (2.2%) in the dalteparin group (unadjusted hazard ratio 1.05; 95% confidence interval, 0.36-3.05). Recurrent VTE occurred in two patients (0.7%) in the edoxaban group and in three patients (1.1%) in the dalteparin group, whereas major bleeding occurred in 5 (1.7%) and three patients (1.1%), respectively.

CONCLUSIONS

The rates of recurrent VTE or major bleeding are relatively low among patients with active cancer receiving extended anticoagulant therapy beyond 6 months. Extended treatment with oral edoxaban appears as effective and safe as subcutaneous dalteparin.

[Treatment of cancer-associated venous thromboembolism]

Most clinical practice guidelines recommend low molecular weight heparin for the treatment of venous thromboembolism (VTE) in cancer patients. In the Hokusai VTE Cancer study, 1050 patients with cancer and acute VTE were randomized to oral edoxaban or subcutaneous dalteparin for at least 6 months and up to 12 months. Edoxaban was non-inferior to dalteparin with respect to the composite outcome of recurrent VTE and major bleeding. The rate of recurrent VTE was numerically lower, but the rate of major bleeding was significantly higher with edoxaban. The frequency of severe major bleeding was similar with edoxaban and dalteparin. The difference in major bleeding was mainly driven by a higher rate of upper gastrointestinal bleeding with edoxaban, especially in patients with gastrointestinal cancer. The pilot Select-D study randomized 406 patients with cancer and VTE to rivaroxaban or dalteparin for 6 months. Recurrent VTE was reduced, while both major and clinically relevant non major bleeding were significantly increased with rivaroxaban. Bleeding mostly involved the gastrointestinal tract and occurred in patients with gastroesophageal cancer. While waiting for ongoing studies on direct oral anticoagulants, the results of the Hokusai VTE Cancer suggest that edoxaban may represent a valuable alternative to low molecular weight heparin for the treatment of cancer-associated VTE. In patients with gastrointestinal cancer, the use of edoxaban requires careful benefit-risk weighting, taking into consideration patient's preferences.

A case report of pulmonary arterial hypertension in pregnancy and complications of anticoagulation therapy

RATIONALE

Treprostinil, a potent vasodilator, is the treatment of choice for severe pulmonary arterial hypertension (PAH) during pregnancy. Its inhibition of platelet aggregation increases the risk of hemorrhage. In addition, anticoagulation therapy is widely used in pregnancy with PAH due to the hypercoagulable state. However, very little is known about the complications of anticoagulants' use in pregnancy with PAH.

PATIENT CONCERNS

A 27-year-old pregnant woman was admitted to the hospital at 32weeks with progressive dyspnea.

DIAGNOSES

The pregnant was diagnosed with ventricular septal defect 12 years prior to presentation. Combining clinical manifestation with results of right heart catheterization (RHC) and echocardiography, it was consistent with severe World Health Organization (WHO) group I PAH.

INTERVENTIONS

Supportive treatment included supplemental oxygen, intravenous treprostinil, sildenafil and prophylactic anticoagulation.

OUTCOMES

Gastrointestinal bleeding is occurred in our patient when dalteparin were used in conjunction with treprostinil. Her care was further complicated refractory to usual conservative measures before delivery.

LESSONS

This case report illustrates the complexities that arise when prostacyclin therapies are combined with necessary anticoagulation in patients with PAH during pregnancy. More intention should play to the complications of anticoagulant in pregnancy with PAH during treprostinil therapy.

Comparative Effectiveness of Enoxaparin vs Dalteparin for Thromboprophylaxis After Traumatic Injury

BACKGROUND

Enoxaparin 30 mg twice daily and dalteparin 5,000 units once daily are two common low-molecular-weight heparin (LMWH) thromboprophylaxis regimens used in the trauma population. Pharmacodynamic studies suggest that enoxaparin provides more potent anticoagulation than does dalteparin.

METHODS

In 2009, our institution switched its formulary LMWH from enoxaparin to dalteparin followed by a switch back to enoxaparin in 2013. Using a difference in differences design, we contrasted the change in the VTE rate accompanying the LMWH switch with the change in a control group of trauma patients given unfractionated heparin (UFH) during the same period.

RESULTS

The study included 5,880 patients: enoxaparin period (enoxaparin, n = 2,371; UFH, n = 1,539) vs the dalteparin period (dalteparin, n = 1,046; UFH, n = 924). The VTE rate was unchanged in the LMWH group: 3.3/1000 days in the enoxaparin period vs 3.8/1000 days in the dalteparin period: rate ratio (RR), 1.16; 95% CI 0.74-1.81. The rate was also unchanged in the UFH control subjects: 5.7/1,000 days in the enoxaparin period vs 5.2/1,000 days in the dalteparin period: RR, 0.92; 95% CI, 0.61-1.38. After confounding adjustment, the ratio of the change in VTE rate between the LMWH and UFH groups was similar: RR, 1.06; 95% CI 0.71-2.00. A secondary analysis excluding patients with delayed or interrupted prophylaxis (or both) altered this estimate nonsignificantly in favor of enoxaparin: RR, 2.39; 95% CI, 0.80-7.09.

CONCLUSIONS

Our results suggest that dalteparin has an effectiveness similar to that of enoxaparin in real-world trauma patients. Future research should investigate how the timing and consistency of prophylaxis affects LMWH effectiveness.

Anti-Xa effect of a low molecular weight heparin (dalteparin) does not accumulate in extended duration therapy for venous thromboembolism in cancer patients

Many patients with venous thromboembolism are being treated with low molecular weight heparin for extended periods of time. It is not certain if it is necessary to assess anti-Xa levels for extended treatment periods. This study is a prospective assessment of anti-Xa levels in patients on long-term therapy for acute venous thromboembolism who have active cancer. Consecutive consenting patients from one center in a multicenter trial that compared 6 months of low molecular weight heparin with oral anticoagulant therapy were treated with therapeutic doses of dalteparin (200 IU per kilogram) subcutaneously daily. Anti-Xa levels were assessed at the end of weeks 1 and 4, 4–6 hours after injection of dalteparin. Patients were followed for bleeding and recurrent venous thromboembolism. There were 24 patients who had anti-Xa levels measured at weeks 1 and 4. Two other patients had week 1 measurements performed but died before the week 4 sample was collected due to their underlying cancer. The mean anti-Xa levels at weeks 1 and 4 were 1.11 and 1.03 anti-Xa units/ml respectively (P=0.13). These results suggest that for patients with active cancer receiving extended duration therapy with low molecular weight heparin (dalteparin) there is no accumulation of anti-Xa effect over the first month of therapy. Monitoring of anti-Xa levels in this situation is usually not required.

High-dose Intravenous Dalteparin Can be Monitored Effectively Using Standard Coagulation Times

The objective of this study was to examine the pharmacokinetics of intravenous dalteparin (Fragmin, Pharmacia-Upjohn, Peapack, NJ) and to assess the accuracy of standard coagulation-based monitoring techniques as an estimate of drug concentration with which to guide dosing. Knowledge of the kinetic behavior of low-molecular-weight heparins (LMWHs) and the possible utility of coagulation times for monitoring may aid in the development of safe and effective dosing algorithms for percutaneous coronary interventions. Twenty normal volunteers were treated at 2-week intervals with each of three intravenous dalteparin doses. Measurement of anti-IIa, anti-Xa, activated partial thromboplastin time (aPTT), activated clotting time (ACT), and low-range ACT was performed at baseline and at seven additional time points over 8 hours. The half-life of intravenous dalteparin is 77 minutes with slight dose-related variation. The aPTT, LR-ACT, and standard ACT are prolonged after dalteparin administration with the increase closely correlated to anti-Xa activity (aPTT, r = 0.85; LR-ACT, r = 0.79). Classification of anticoagulation intensity range using aPTT or LR-ACT in comparison to anti-Xa activity (0.5-0.99, 1.0-1.49, 1.5-2, >2) displays a level of agreement (kappa: aPTT = 0.69, LR-ACT = 0.59) that is comparable to values reported for coagulation time guidance of unfractionated heparin administration. Standard coagulation times are sensitive to the anticoagulant effect of dalteparin with a degree of correlation that suggests their utility for estimating drug concentration during high dose therapy. Trials establishing a relationship between monitoring and clinical efficacy, and the risk/reward of different treatment ranges alone or in combination with GPIIb/IIIa inhibitors and clopidogrel, are necessary.

Comparison of the effect of dabigatran and dalteparin on thrombus stability in a murine model of venous thromboembolism

ESSENTIALS: Does thrombus stability alter the presentation of venous thromboembolism and do anticoagulants alter this? In a murine model, we imaged a femoral vein thrombus and quantified emboli in the pulmonary arteries. Dabigatran decreases thrombus stability via factor XIII increasing embolization and pulmonary emboli. This cautions against the unapproved use of dabigatran for acute initial treatment of deep vein thrombosis.

BACKGROUND

Venous thromboembolism (VTE) is a collective term for deep vein thrombosis (DVT) and pulmonary embolism (PE). Thrombus instability possibly contributes to progression of DVT to PE, and direct thrombin inhibitors (DTIs) may alter this.

AIM

To develop a model to assess thrombus stability and its link to PE burden, and identify whether DTIs, in contrast to low-molecular-weight heparin (LMWH), alter this correlation.

METHODS

Twelve minutes after ferric chloride-induced thrombus formation in the femoral vein of female mice, saline, dalteparin (LMWH) or dabigatran (DTI) was administered. Thrombus size and embolic events breaking off from the thrombus were quantified before treatment and at 10-min intervals after treatment for 2 h using intravital videomicroscopy. Lungs were stained for the presence of PE.

RESULTS

Thrombus size was similar over time and between treatment groups. Total and large embolic events and pulmonary emboli were highest after treatment with dabigatran. Variations in amounts of pulmonary embolic events were not attributed to variations in thrombus size. Large embolic events correlated with the number of emboli per lung slice independent of treatment. Embolization in factor XIII deficient (FXIII(-/-) ) saline-treated mice was greater than that in wild-type (WT) saline-treated mice, but was similar to WT dabigatran-treated mice.

CONCLUSION

We have developed a mouse model of VTE that can quantify emboli and correlate this with PE burden. Consistent with clinical data, dabigatran, a DTI, acutely decreases thrombus stability and increases PE burden compared with LMWH or saline, which is a FXIII-dependent effect.

Treatment for superficial infusion thrombophlebitis of the upper extremity

BACKGROUND

Although superficial thrombophlebitis of the upper extremity represents a frequent complication of intravenous catheters inserted into the peripheral veins of the forearm or hand, no consensus exists on the optimal management of this condition in clinical practice.

OBJECTIVES

To summarise the evidence from randomised clinical trials (RCTs) concerning the efficacy and safety of (topical, oral or parenteral) medical therapy of superficial thrombophlebitis of the upper extremity.

SEARCH METHODS

The Cochrane Vascular Group Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and the Cochrane Register of Studies (2015, Issue 3). Clinical trials registries were searched up to April 2015.

SELECTION CRITERIA

RCTs comparing any (topical, oral or parenteral) medical treatment to no intervention or placebo, or comparing two different medical interventions (e.g. a different variant scheme or regimen of the same intervention or a different pharmacological type of treatment).

DATA COLLECTION AND ANALYSIS

We extracted data on methodological quality, patient characteristics, interventions and outcomes, including improvement of signs and symptoms as the primary effectiveness outcome, and number of participants experiencing side effects of the study treatments as the primary safety outcome.

MAIN RESULTS

We identified 13 studies (917 participants). The evaluated treatment modalities consisted of a topical treatment (11 studies), an oral treatment (2 studies) and a parenteral treatment (2 studies). Seven studies used a placebo or no intervention control group, whereas all others also or solely compared active treatment groups. No study evaluated the effects of ice or the application of cold or hot bandages. Overall, the risk of bias in individual trials was moderate to high, although poor reporting hampered a full appreciation of the risk in most studies. The overall quality of the evidence for each of the outcomes varied from low to moderate mainly due to risk of bias and imprecision, with only single trials contributing to most comparisons. Data on primary outcomes improvement of signs and symptoms and side effects attributed to the study treatment could not be statistically pooled because of the between-study differences in comparisons, outcomes and type of instruments to measure outcomes.An array of topical treatments, such as heparinoid or diclofenac gels, improved pain compared to placebo or no intervention. Compared to placebo, oral non-steroidal anti-inflammatory drugs reduced signs and symptoms intensity. Safety issues were reported sparsely and were not available for some interventions, such as notoginseny creams, parenteral low-molecular-weight heparin or defibrotide. Although several trials reported on adverse events with topical heparinoid creams, Essaven gel or phlebolan versus control, the trials were underpowered to adequately measure any differences between treatment modalities. Where reported, adverse events with topical treatments consisted mainly of local allergic reactions. Only one study of 15 participants assessed thrombus extension and symptomatic venous thromboembolism with either oral non-steroidal anti-inflammatory drugs or low-molecular-weight heparin, and it reported no cases of either. No study reported on the development of suppurative phlebitis, catheter-related bloodstream infections or quality of life.

AUTHORS' CONCLUSIONS

The evidence about the treatment of acute infusion superficial thrombophlebitis is limited and of low quality. Data appear too preliminary to assess the effectiveness and safety of topical treatments, systemic anticoagulation or oral non-steroidal anti-inflammatory drugs.

Competing Risk Analysis for Evaluation of Dalteparin Versus Unfractionated Heparin for Venous Thromboembolism in Medical-Surgical Critically Ill Patients

Failure to recognize the presence of competing risk or to account for it may result in misleading conclusions. We aimed to perform a competing risk analysis to assess the efficacy of the low molecular weight heparin dalteparin versus unfractionated heparin (UFH) in venous thromboembolism (VTE) in medical-surgical critically ill patients, taking death as a competing risk.This was a secondary analysis of a prospective randomized study of the Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT) database. A total of 3746 medical-surgical critically ill patients from 67 intensive care units (ICUs) in 6 countries receiving either subcutaneous UFH 5000 IU twice daily (n = 1873) or dalteparin 5000 IU once daily plus once-daily placebo (n = 1873) were included for analysis.A total of 205 incident proximal leg deep vein thromboses (PLDVT) were reported during follow-up, among which 96 were in the dalteparin group and 109 were in the UFH group. No significant treatment effect of dalteparin on PLDVT compared with UFH was observed in either the competing risk analysis or standard survival analysis (also known as cause-specific analysis) using multivariable models adjusted for APACHE II score, history of VTE, need for vasopressors, and end-stage renal disease: sub-hazard ratio (SHR) = 0.92, 95% confidence interval (CI): 0.70-1.21, P-value = 0.56 for the competing risk analysis; hazard ratio (HR) = 0.92, 95% CI: 0.68-1.23, P-value = 0.57 for cause-specific analysis. Dalteparin was associated with a significant reduction in risk of pulmonary embolism (PE): SHR = 0.54, 95% CI: 0.31-0.94, P-value = 0.02 for the competing risk analysis; HR = 0.51, 95% CI: 0.30-0.88, P-value = 0.01 for the cause-specific analysis. Two additional sensitivity analyses using the treatment variable as a time-dependent covariate and using as-treated and per-protocol approaches demonstrated similar findings.This competing risk analysis yields no significant treatment effect on PLDVT but a superior effect of dalteparin on PE compared with UFH in medical-surgical critically ill patients. The findings from the competing risk method are in accordance with results from the cause-specific analysis.clinicaltrials.gov Identifier: NCT00182143.

Anticoagulation with dalteparin and nadroparin in nocturnal haemodialysis

BACKGROUND

Low-molecular-weight heparins (LMWHs) are increasingly used as anticoagulant during haemodialysis. The aim of this study is to establish the efficiency and duration of anticoagulation with dalteparin and nadroparin administration in patients treated with nocturnal haemodialysis.

METHODS

All patients were treated with nocturnal in-centre haemodialysis, 3-4 times a week. Anticoagulation was obtained with dalteparin (n = 15) or nadroparin (n = 10). Anti-factor- Xa activity was measured during a midweek dialysis session at t = 0, 4 and 8 hours.

RESULTS

The LMWH dose necessary to prevent extracorporeal circuit clotting was higher for dalteparin than for nadroparin. In the dalteparin group, anti-Xa activity was almost negligible at the start of dialysis whereas most patients on nadroparin still had anti-Xa activity at the start of dialysis (0.08 (IQR 0.05-0.11) IU÷ml), reflecting the effect of previous LMWH administration. After eight hours of dialysis, median anti-factor-Xa activity was 0.49 (IQR 0.22-0.57) after dalteparin and 0.69 (IQR 0.55- .83) after nadroparin (p = 0.01). When a target range of 0.2-0.6 IU÷ml was applied, the present dosing method led to over-anticoagulation in more than half of the patients.

CONCLUSION

Administration of two doses of LMWH is an effective method of anticoagulation in nocturnal, eight-hour haemodialysis. With two doses of dalteparin, a larger proportion of patients reached but did not exceed target levels of anticoagulation, compared with two doses of nadroparin. Nadroparin caused prolonged anti-Xa activity with measurable anticoagulation up to the next dialysis session. The measurement of anti-Xa activity is advocated for dose assessment of LMWH, when LMWH is used as anticoagulant during nocturnal haemodialysis.

Treatment of venous thromboembolism in cancer patients with dalteparin for up to 12 months: the DALTECAN Study

BACKGROUND

Treatment of venous thromboembolism (VTE) in patients with cancer has a high rate of recurrence and bleeding complications. Guidelines recommend low-molecular-weight heparin (LMWH) for at least 3-6 months and possibly indefinitely for patients with active malignancy. There are, however, few data supporting treatment with LMWH beyond 6 months. The primary aim of the DALTECAN study (NCT00942968) was to determine the safety of dalteparin between 6 and 12 months in cancer-associated VTE.

METHODS

Patients with active cancer and newly diagnosed VTE were enrolled in a prospective, multicenter study and received subcutaneous dalteparin for 12 months. The rates of bleeding and recurrent VTE were evaluated at months 1, 2-6 and 7-12.

FINDINGS

Of 334 patients enrolled, 185 and 109 completed 6 and 12 months of therapy; 49.1% had deep vein thrombosis (DVT); 38.9% had pulmonary embolism (PE); and 12.0% had both on presentation. The overall frequency of major bleeding was 10.2% (34/334). Major bleeding occurred in 3.6% (12/334) in the first month, and 1.1% (14/1237) and 0.7% (8/1086) per patient-month during months 2-6 and 7-12, respectively. Recurrent VTE occurred in 11.1% (37/334); the incidence rate was 5.7% (19/334) for month 1, 3.4% (10/296) during months 2-6, and 4.1% (8/194) during months 7-12. One hundred and sixteen patients died, four due to recurrent VTE and two due to bleeding.

CONCLUSION

Major bleeding was less frequent during dalteparin therapy beyond 6 months. The risk of developing major bleeding complications or VTE recurrence was greatest in the first month of therapy and lower over the subsequent 11 months.

[Anticoagulation for continuous renal replacement therapy in the intensive care unit: a comparison of dalteparin infusion with regional citrate anticoagulation]

Continuous renal replacement therapy (CRRT) is used to treat severe acute kidney injury in intensive care units. The aim of this study was to compare two anticoagulation techniques in CRRT, the infusion of dalteparin and regional citrate-calcium anticoagulation, in terms of efficacy and safety. In a retrospective study, we analysed data on 77 dalteparin and 75 citrate-calcium treatment periods. The primary endpoint was the life span of the CRRT circuit. The use of regional anticoagulation with citrate and calcium resulted in a significantly longer CRRT circuit life span as compared to that achieved with dalteparin infusion.

Multicenter dose-finding and efficacy and safety outcomes in neonates and children treated with dalteparin for acute venous thromboembolism

BACKGROUND

Low molecular weight heparins (LMWHs) constitute the mainstay of anticoagulant therapy for pediatric venous thromboembolism (VTE). The safety and effectiveness of dalteparin, an LMWH, has not been established in children, and pediatric data on dalteparin for VTE are limited to one single-center experience.

OBJECTIVE

To establish dose-finding (primary endpoint) and efficacy/safety outcomes (secondary endpoints) in children treated with dalteparin in a substudy of the Kids-DOTT trial.

PATIENTS AND METHODS

A prospective multicenter trial using dalteparin subcutaneously twice daily for acute VTE in children aged ≤ 21 years was conducted under an investigator-held Investigational New Drug application registered with the US Food and Drug Administration. Initial weight-based dosing per protocol was as follows: infants (< 12 months), 150 IU kg(-1) ; children (1-12 years), 125 IU kg(-1) ; and adolescents (13-18 years), 100 IU kg(-1) . Bleeding events were categorized according to ISTH criteria. Descriptive non-parametric statistics were employed for all analyses.

RESULTS

Eighteen patients (67% male) were enrolled from January 2010 to October 2013 across four centers. No supratherapeutic levels were observed. Median (range) therapeutic doses by age group were as follows: infants (n = 3), 180 IU kg(-1) (146-181 IU kg(-1) ); children (n = 7), 125 IU kg(-1) (101-175 IU kg(-1) ); and adolescents (n = 8), 100 IU kg(-1) (91-163 IU kg(-1) ). The median duration of dalteparin use was 48 days (range: 2-169 days), and the median follow-up was 10.5 months (range: 2-35 months). There were no related serious adverse events, no clinically relevant bleeding events, and no symptomatic recurrent VTEs.

CONCLUSION

Dalteparin successfully achieved targeted anti-factor Xa levels in 18 children and young adults with acute VTE with a standardized age-based dosing regimen, with a favorable safety and efficacy profile.

The value of extended preoperative thromboprophylaxis with dalteparin in patients with ovarian cancer qualified to surgical treatment

AIM

Ovarian cancer (OC) is associated with a high risk of venous thromboembolism (VTE) in both, pre- and postoperative period. The aim of the study was to analyse the efficacy and the safety of an early prophylaxis with dalteparin in patients with OC qualified to surgery.

METHODS

The prospective, non-randomized study was performed in the group of OC patients qualified to surgical treatment. The study group (SG) consisted of 37 patients with OC in whom thromboprophylaxis was started at the moment of qualification to the surgery (mean 16,1 days ± 11,32 SD before procedure). The control group (CG) consisted of 61 patients with OC qualified to surgery in whom thromboprophylaxis was started 12 hour before surgical treatment. The duration of postoperative prophylaxis was 4 weeks in both groups. Dalteparin 5000 U/day was used in both groups. The primary end points were occurrence of VTE and major bleeding. The patients underwent color Doppler US and D-dimer (DD) assessment at the moment of qualification for surgery, 1 day before and 7, 14, 28 days and 3 months after procedure.

RESULTS

The total duration of thromboprophylaxis was 45.3 ± 10.7 days in SG and 27.9 ± 3.7 days in CG (P < 0.0001). The deep venous thrombosis rate was 2,7% in SG and 16.4% in CG (P = 0.042). Neither pulmonary embolism, nor major bleeding were observed. Median preoperative DD concentration in all patients was 1700 ng/ml and was significantly higher in patients who developed postoperative DVT when compared to those who did not, 2556.8 and 1691.0 ng/mL respectively (P = 0.0009).

CONCLUSION

Prolonged preoperative thromboprophylaxis with dalteparin in patients with ovarian cancer qualified to the surgical treatment is safe, decreases the risk of thromboembolic complications. To determine indication, dosage and timing of such thromboprophylaxis in this group of patients further studies are required.

[Subcutaneous catheter used for administration of low-molecular-weight-heparin in pediatrics]

INTRODUCTION

Subcutaneous catheter is a device easy to assemble, which was created for the administration of insulin in diabetic patients, especially in children, aiming to reduce the number of punctures, pain and anxiety of patients and their parents.

OBJECTIVE

To describe the experience using the catheter for subcutaneous administration of low molecular weight heparin (LMWH) in hospitalized pediatric patients.

PATIENTS AND METHOD

A prospective descriptive study in 28 patients who used 87 subcutaneous catheters for the administration of LMWH in the Pediatric Service of the Universidad Catolica de Chile between July, 2010 and November, 2011.

RESULTS

Complications associated with the catheter had an incidence of 33 % in total catheters evaluated; the most frequent complication was the presence of hematoma at the site of insertion (26%). These complications occurred more frequently in male (38% versus 31% in females) and younger patients (9 months versus 12 months), who received dalteparin (54% versus 30% of other types of heparin) administered every 24 hours (41% versus 30%, administered every 12 hours), and when the catheter was located on both thighs (36 % versus 32% in both arms); however, these differences were not statistically confirmed.

CONCLUSION

The subcutaneous catheter is a good technique to be considered for LMWH in children as it presents minor complications for drug administration.

A randomized trial of dalteparin compared with ibuprofen for the treatment of superficial thrombophlebitis

BACKGROUND

Superficial thrombophlebitis can produce pain and result in a deep vein thrombosis (DVT) if not treated. Conservative therapies including prescription of non-steroidal anti-inflammatory drugs (NSAID) and heat have been standard care. Recently, studies have been published reporting efficacy and safety of low-molecular-weight heparin for the treatment of superficial thrombophlebitis. However, there are few comparative trials to conservative therapy. We studied the effectiveness and safety of treatment with dalteparin compared with ibuprofen in patients with confirmed superficial thrombophlebitis.

METHODS

Consecutive patients were randomized to receive daily dalteparin vs. ibuprofen three times daily for up to 14 days. The primary outcome measure was the incidence of extension of thrombus or new symptomatic venous thromboembolism during the 14-day and 3-month follow-up period. The secondary outcome was a reduction in pain. The outcome measure of safety was the incidence of major and minor bleeding.

RESULTS

Of 302 consecutive patients screened, 72 were enrolled. Four patients receiving ibuprofen compared with no patients receiving dalteparin had thrombus extension at 14 days (P = 0.05), however, there was no difference in thrombus extension at 3 months. Both treatments significantly reduced pain. There were no episodes of major or minor bleeding during the treatment period.

CONCLUSIONS

Dalteparin is superior to the NSAID ibuprofen in preventing extension of superficial thrombophlebitis during the 14-day treatment period with similar relief of pain and no increase in bleeding. However, questions concerning the optimal treatment duration should be explored in future trials.

Pharmacokinetics of the low molecular weight heparin dalteparin in cats

Low molecular weight heparin (LMWH) is used as an anticoagulant in cats although only limited pharmacokinetic data are available in this species. The aim of the present study was to establish the pharmacokinetics of dalteparin in cats based on anti-FXa heparin activities. Groups of clinically healthy cats (six animals per treatment) received individual LMWH injections at three different doses intravenously (IV) (25, 50, 100 anti-factor Xa international units [IU anti-FXa]/kg) or subcutaneously (SC) (50, 100, 200 IU anti-FXa/kg). Blood samples were collected before and at various times after injection. Anti-FXa activity was measured with a chromogenic substrate test. Following IV injection, maximum plasma heparin activities (C(max)) were 0.67 ± 0.14, 1.44 ± 0.22 and 2.87 ± 0.38 IU anti-FXa/mL, respectively. The calculated mean half-life (t(½)) was between 39 and 57 min and was not significantly dose-dependent (P=0.139). The volume of distribution (35-39 mL/kg) was almost equivalent to the plasma volume. After SC injection, C(max) values of 0.41 ± 0.10, 0.86 ± 0.17 or 1.91 ± 0.16 IU anti-FXa/mL, respectively, were calculated at 91-110 min post-injection. The t(½) values were between 106 and 122 min and were not significantly influenced by dose (P=0.784). The bioavailability after SC injection was approximately 100%. The high bioavailability of the SC administered LMWH dalteparin in cats was consistent with other species and indicated predictable blood levels. However, the comparatively short t(½) may indicate the necessity of multiple daily injections, which should be verified in clinical trials.

Treatment of upper-extremity deep vein thrombosis

BACKGROUND

Upper extremity deep vein thrombosis (DVT) can result in fatal pulmonary embolism if not treated. Patients with malignancy may be at particularly high risk. Heparin or low-molecular-weight heparin followed by warfarin has been used as standard treatment for lower extremity DVT. However, a paucity of studies exist reporting the efficacy and safety of these regimens in patients with upper extremity DVT. We studied the effectiveness and safety of treatment with dalteparin sodium followed by warfarin and also dalteparin sodium monotherapy for 3 months in patients with confirmed upper extremity DVT.

METHODS

Consecutive patients with confirmed upper extremity DVT received daily dalteparin sodium for 5-7 days followed by warfarin therapy for 3 months (phase I) or dalteparin sodium monotherapy for 3 months (phase II). The primary outcome measure was the incidence of new symptomatic venous thromboembolism during the 3-month follow-up period. The outcome measure of safety was the incidence of major and minor bleeding.

RESULTS

Of 631 consecutive patients screened, 74 were eligible and 67 enrolled. No patients receiving either phase I (0%; 95% CI, 0-12%) or phase II (0%; 95% CI, 0-9%) therapy had venous thromboembolism on 3-month follow-up. One patient (4%; 95% CI, 0-18%) receiving phase I therapy experienced major bleeding. Five patients died during the follow-up period; none were attributed to pulmonary embolism.

CONCLUSIONS

Patients with upper extremity DVT may be treated safely with either dalteparin sodium followed by warfarin or dalteparin sodium monotherapy for 3 months with a good prognosis.

Comparison of tirofiban combined with dalteparin or unfractionated heparin in primary percutaneous coronary intervention of acute ST-segment elevation myocardial infarction patients

BACKGROUND

Primary percutaneous coronary intervention (PCI) is the best treatment of choice for acute ST segment elevation myocardial infarction (STEMI). This study aimed to determine the clinical outcomes of tirofiban combined with the low molecular weight heparin (LMWH), dalteparin, in primary PCI patients with acute STEMI.

METHODS

From February 2006 to July 2006, a total of 120 patients with STEMI treated with primary PCI were randomised to 2 groups: unfractionated heparin (UFH) with tirofiban (group I: 60 patients, (61.2 ± 9.5) years), and dalteparin with tirofiban (group II: 60 patients, (60.5 ± 10.1) years). Major adverse cardiac events (MACE) during hospitalization and at 4 years after PCI were examined. Bleeding complications during hospitalization were also examined.

RESULTS

There were no significant differences in sex, mean age, risk factors, past history, inflammatory marker, or echocardiography between the 2 groups. In terms of the target vessel and vascular complexity, there were no significant differences between the 2 groups. During the first 7 days, emergent revascularization occurred only in 1 patient (1.7%) in group I. Acute myocardial infarction (AMI) occurred in 1 (1.7%) patient in group I and in 1 (1.7%) in group II. Three (5.0%) patients in group I and 1 (1.7%) in group II died. Total in-hospital MACE during the first 7 days was 4 (6.7%) in group I and 2 (3.3%) in group II. Bleeding complications were observed in 10 patients (16.7%) in group I and in 4 patients (6.7%) in group II, however, the difference was not statistically significant. No significant intracranial bleeding was observed in either group. Four years after PCI, death occurred in 5 (8.3%) patients in group I and in 4 (6.7%) in group II. MACE occurred in 12 (20.0%) patients in group I and in 10 (16.7%) patients in group II.

CONCLUSIONS

Dalteparin was effective and safe in primary PCI of STEMI patients and combined dalteparin with tirofiban was effective and safe without significant bleeding complications compared with UFH. Although there was no statistically significant difference, LMWH decreased the bleeding complications compared with UFH.

Dosing and monitoring of low-molecular-weight heparin in high-risk pregnancy: single-center experience

STUDY OBJECTIVE

To evaluate dosing requirements and monitoring patterns of low-molecular-weight heparin (LMWH) when used in high-risk pregnancy.

DESIGN

Retrospective, observational, cohort study.

SETTING

University-affiliated medical center.

PATIENTS

Forty-nine women treated with LMWH between 2001 and 2005 for either prophylaxis or treatment of venous thromboembolism during pregnancy and monitored with antifactor Xa activity.

MEASUREMENTS AND MAIN RESULTS

Data were obtained on 53 pregnancies in the 49 women. The primary outcome was change in dosing requirements of LMWH throughout pregnancy as determined by the corresponding antifactor Xa activity peak levels. Mean starting doses of twice-daily enoxaparin and doses most proximate to delivery were 39.2 mg (range 30-60 mg) and 55.0 mg (range 30-100 mg, p=0.06), respectively, for the prophylaxis group and 83.0 mg (range 30-180 mg) and 85.7 mg (range 30-160 mg, p=0.41), respectively, for the therapeutic group. Weight-based mean starting doses and doses most proximate to delivery were 0.46 and 0.62 mg/kg (p=0.03), respectively, for the prophylaxis group and 0.90 and 0.87 mg/kg (p=0.29), respectively, for the therapeutic group. Dose changes were required in 9 (69%) of 13 pregnancies and 21 (55%) of 38 pregnancies (data from two of the 40 pregnancies were excluded-one in a patient receiving dalteparin, and one in a patient with mitral valve replacement who had higher antifactor Xa goals) in the prophylaxis and therapeutic groups, respectively, to achieve target antifactor Xa activity. The weight-based prophylactic dose was consistently 0.6 mg/kg in all three trimesters, achieving a mean ± SD target antifactor Xa activity of 0.39 ± 0.18 units/ml, whereas the therapeutic dose was 0.9 mg/kg to maintain antifactor Xa activity of 0.71 ± 0.22 units/ml.

CONCLUSION

Dose changes for LMWH throughout pregnancy as guided by antifactor Xa activity were common. A significant increase in the LMWH dose requirements in the prophylactic group suggests that more frequent monitoring of antifactor Xa activity may be appropriate in pregnant patients to maintain target anticoagulant levels.

[Effects of anticoagulant therapy for rapidly progressive interstitial pneumonias]

To clarify the effects of anticoagulant therapy, we investigated patients with rapidly progressive interstitial pneumonias, retrospectively. We defined rapidly progressive pneumonia as idiopathic or secondary interstitial pneumonia with acute exacerbation of respiratory symptoms within 2 months, without infection or heart failure. A total of 20 cases admitted to our hospital between April 1999 and January 2010 met our criteria. Of those 20 cases, 6 were non-idiopathic pulmonary fibrosis (non-IPF), 3 were IPF, 6 were amyopathic dermatomyositis (ADM), 2 were DM, 2 were rheumatoid arthritis, and 1 was mixed connective-tissue disease. We divided the 20 cases into two groups according to whether they were treated with anticoagulant therapy (dalteparin and/or warfarin) (group A, n = 11) or not (group B, n = 9), and compared their outcomes. They were all given standard therapy. There was significantly better survival time in group A than in group B by the Kaplan-Meier survival curve (p = 0.0389). Anticoagulant therapy may improve the survival of patients with rapidly progressive interstitial pneumonias.

[Administration of dalteparin in reconstructive vascular surgery]

The article contains a review of the literature regarding the use of low-molecular-weight heparins (LMWHs) exemplified by dalteparin in the hitherto insufficiently explored area of their implementation, i. e., during the intraoperative period in patients suff ering from atherothrombosis. Presented herein is analysis of alterations in the parameters of the plasmatic and thrombocytic links of haemostatis during intraoperative administration of various molecular-weight fractions of heparin. The obtained findings make it possible to conclude that LMWHs do off er certain advantages when used during surgical interventions in patients with atherosclerotic lesions of the arterial bed.

[Prolonged prophylaxis of thromboembolic disease in patients with colorectal surgical resections for malignancy]

Cancer patients have 6-fold higher risk of venous thromboembolism compared with patients without malignancy. This risk of VTE is further increased by cancer surgery.

AIM OF THE STUDY

The aim of our pilot study was to examine the changes in inflammatory reaction, changes of coagulation parameters and inhibition of FXa in patients with new diagnosed colorectal cancer. During 30 days of observation prophylactic dose of dalteparin 5000 UI subcutaneously once daily was administrated.

PATIENTS AND METHODS

Patients who underwent surgical resection of the colon for new diagnosed colorectal cancer were included in the study. Laboratory tests (blood count, acute phase proteins--alpfa-1-antitrypsin, transferin, prealbumin, alpfa-2-makroglobulin, orosomukoid and C reactive protein and coagulation laboratory tests--PT in INR, aPTT, TT, fibrinogen concentration, activity of antithrombinu and concentration of D-dimer) were performed before surgery and on day 3, 10 and 30 after surgery.

RESULTS

Inflammatory response reached highest level on day 3, lasted until day 10 after surgery than parameters returned to normal values (p < 0.05). Hypercoagulable tendency was already seen before surgery, highest value of D-dimer was measured on day 10 after surgery and after decrease it lasted until the day 30 after surgery (p < 0.05). Inhibition of FXa varied between 0.02-0.7 IU/ml. The prophylactic range of FXa inhibition 0.2-0.4 IU/ml was reached in 48.1% of the samples, 20.4% of the samples were over the range and 31.5% were under the prophylactic range. During 30 day of observation deep vein thrombosis was not detected in any patient as well as bleeding complication.

CONCLUSION

The pilot study shows that prolonged prophylaxis of VTE is advisable in patients after cancer surgery. Variation of FXa inhibition will be in our study further examined.

Study of bioaccumulation of dalteparin at a therapeutic dose in patients with renal insufficiency

BACKGROUND

Low-molecular-weight heparins (LMWH) are effective, safe and convenient for anticoagulation. Their use is limited in patients with renal insufficiency (RI) because of bioaccumulation.

OBJECTIVES

Evaluate pharmacokinetic data of dalteparin at a therapeutic dose in patients with RI.

PATIENTS AND METHODS

Prospective observational cohort study. Inpatients were included into three groups according to glomerular filtration rate (GFR): A > or = 60, B 30-59, C < 30 mL min(-1) 1.73 m(-2). Dalteparin was injected subcutaneously (s.c.) twice daily. Peak plasma anti-factor Xa activity (anti-Xa) was measured and adjusted to applied dose and body weight after the first dose, on day 2, and every 2nd day afterwards. Bioaccumulation factor R was calculated as quotient of the last and the first adjusted anti-Xa. Data are shown as median (interquartile range, IQR).

RESULTS

Thirty-two patients (23 men) receiving dalteparin for > or = 2 days were analyzed. Follow-up was 6 days (IQR 4-10, range 2-22). Median dose was 90 (73-106) units kg(-1) per 12 h (P = 0.68). After the first dose, adjusted anti-Xa levels were 3.5 (2.6-5.0), 4.8 (3.3-5.5), 4.5 (3.7-7.5) x 10(-3) for the groups A, B, C; P = 0.26. On the last day, they were 6.1 (3.7-7.3), 7.1 (5.6-8.3), 10.2 (7.8-13.2) x 10(-3); A compared with C, P = 0.002. R was 1.46 (1.15-1.82), 1.36 (1.20-2.16) and 2.28 (1.53-2.93); A compared with C, P = 0.18.

CONCLUSION

Therapeutically dosed dalteparin accumulates in patients with severe RI (group C). Dose adjustments according to anti-Xa are recommended for dalteparin if used in this patient population. However, no simple dosing scheme can be suggested yet because of wide inter-individual variation.

Effects of heparin and dalteparin on oxidative stress during hemodialysis in patients with end-stage renal disease

INTRODUCTION

Dialysis-induced oxidative stress is one of the mechanisms of atherosclerotic changes. Heparin, used in hemodialysis, is an anticoagulant drug with anti-inflammatory and antioxidant effects. This study was planned in order to evaluate the antioxidant effects of heparin and dalteparin (low-molecular weight heparin).

MATERIALS AND METHODS

Twenty-two patients underwent 3 hemodialysis sessions with 48-hour intervals. They underwent hemodialysis with heparin, with a bolus dose of 1000 U followed by 1000 U/h during the procedure. The second hemodialysis was done using hypertonic saline solution instead of heparin, and the third, using dalteparin, 4000 U, infused during hemodialysis. Before and after each dialysis session, we measured serum levels of total blood cholesterol, triglyceride, high- and low-density lipoprotein cholesterols and oxidized low-density lipoprotein cholesterol, in addition to total antioxidant capacity and paraoxonase 1 activity.

RESULTS

Serum concentrations of triglyceride, cholesterol, and oxidized low-density lipoprotein cholesterol, as well as paraoxonase activity and total antioxidant capacity equally increased after the three hemodialysis sessions. Heparin and daltepain increased total antioxidant capacity, but they did not change the ratio of paraoxonase 1 to high-density lipoprotein cholesterol after hemodialysis. No significant differences were found through the study between the two heparin products in their antioxidant activities.

CONCLUSIONS

Regarding these findings and considering higher price and less availability of dalteparin in comparison to conventional heparin, we recommend using conventional heparin during hemodialysis as the anticoagulant-antioxidant agent.

Study of bioaccumulation of dalteparin at a prophylactic dose in patients with various degrees of impaired renal function

BACKGROUND

Low-molecular-weight heparins (LMWH) have been shown to be effective and safe for prophylaxis of thromboembolic diseases. However, issues regarding safety and optimal use of LMWH arise in patients with renal insufficiency (RI).

OBJECTIVES

To compare pharmacokinetic data of dalteparin for up to 3 weeks in patients with various degrees of RI.

PATIENTS AND METHODS

Patients from general medical and surgical wards were included in this prospective cohort study and divided into three groups according to renal function: A=normal (GFR>or=60 mL min(-1)1.73 m(-2)), B=mild RI (GFR 30-59 mL min(-1)1.73 m(-2)), C=severe RI (GFR<30 mL min(-1)1.73 m(-2)). Dalteparin was injected s.c. once daily at a prophylactic dose. Peak anti-Xa activity levels (anti-Xa) were measured 4+/-1 h after injection on day 1 and every third day up to 3 weeks. Primary objectives were peak anti-Xa levels and adjusted anti-Xa levels, adjustment being carried out for dose and body weight.

RESULTS

A total of 42 patients could be analyzed during a median of 10 days (interquartile range IQR 4-13, range 1-20). In all groups, adjusted peak anti-Xa levels were not different on day 10 compared with day 1. No bioaccumulation>30% could be found up to day 10 even in patients with severe RI.

CONCLUSION

The use of dalteparin at a prophylactic dose was not associated with a bioaccumulation>30% even in patients with severe renal insufficiency during a median follow-up of 10 days (IQR 4-13, range 1-20).

Low molecular weight heparin for acute ischemic heart disease

LMWH seems to me to be an attractive antithrombotic therapy that can be used in combination with antiplatelet treatment in patients with acute coronary syndromes. One of the advantages of LMWH is that home treatment becomes a possibility since the agent can be administered as subcutaneous injection without monitoring coagulation times. Therefore, in some patients, once they are stabilized and past the acute event, outpatient subcutaneous treatment with LMWH could be an attractive alternative to impatient treatment with intravenous heparin.

Improving outcomes in acute coronary syndromes--the FRISC II trial

The FRISC II study addressed two key questions in the management of acute coronary syndromes: is it beneficial to extend low-molecular-weight heparin (LMWH) therapy with dalteparin beyond the initial period of acute treatment; and, is a strategy of early invasive therapy, including angioplasty and surgical revascularization, preferable to a more conservative strategy? The study focused on patients with unstable coronary artery disease (UCAD), that is, angina and non-ST-segment-elevation myocardial infarction (MI). Patients were allocated in a randomized, factorial study design to either an invasive or a conservative management strategy. Within each of these groups, patients were further randomized to receive either 3 months of extended treatment with dalteparin or placebo, following at least 5 days' treatment with open-label dalteparin. After 1 year, patient survival and MI-free survival were significantly higher in the invasive therapy group than in the noninvasive group. Patients who received extended dalteparin treatment had a significantly reduced probability of death or MI after 1 month (relative risk reduction 47%; p = 0.002), a benefit still evident after 60 days, but after 3 months there was no longer any significant clinical advantage compared with placebo. There was, however, a significant reduction in the combined incidence of death, MI, or revascularization at 3 months in the extended dalteparin treatment group (relative risk reduction 13%; p = 0.031). The benefits of extended dalteparin treatment were particularly marked in patients with elevated troponin-T or ST-segment depression. A subgroup analysis of conservatively managed patients who underwent revascularization in the first 45 days revealed that the probability of death or MI at 1 year was significantly lower among patients who received extended dalteparin treatment (relative risk reduction 35%; p = 0.02). Extended dalteparin treatment is, however, associated with a small increase in bleeding risk. In conclusion, early invasive therapy (following combined treatment with aspirin and dalteparin) is recommended in a majority of patients with UCAD. Furthermore, extended dalteparin treatment for up to 45 days is efficacious and well tolerated, and therefore provides a useful "bridge" to revascularization when early revascularization is not immediately available.

The low-molecular-weight heparin dalteparin as adjuvant therapy in acute myocardial infarction: the ASSENT PLUS study

Rapid reperfusion of an infarct-related artery reduces the extent of myocardial damage and improves survival in acute myocardial infarction (AMI). Currently, anticoagulant treatment with unfractionated heparin (UFH) is used as adjuvant therapy to fibrinolytic treatment. The low-molecular-weight heparin (LMWH) dalteparin is at least as effective as UFH in unstable coronary artery disease. The ASSENT PLUS trial was carried out to evaluate whether dalteparin is as effective as UFH as an adjunct to recombinant tissue-plasminogen activator (rt-PA) and aspirin in obtaining patency and Thrombolysis in Myocardial Infarction (TIMI)-3 flow in patients with AMI. The primary assessment of this phase II trial was TIMI flow, determined by coronary angiography. Patients with ST-elevation MI were randomized to receive aspirin and either rt-PA and UFH for 48 h, or rt-PA and dalteparin for 4 to 7 days. Evaluation was by TIMI flow after 4 to 7 days and clinical events (death, reinfarction, or revascularization) up to 30 days. There was a clear trend toward greater TIMI 3 flow with dalteparin compared with UFH. There was significantly less TIMI 0-1 flow or thrombus in the dalteparin group. Bleeding rates were similar. The occurrence of reinfarction was reduced during dalteparin treatment. These findings suggest that dalteparin could be substituted for UFH as an adjunct to rt-PA/aspirin in the management of patients with AMI.

A novel point-of-care assay for the monitoring of low-molecular weight heparins in the cardiac catheterization laboratory

BACKGROUND

We designed a study to compare the novel point-of-care assay Hemonox clotting time (Hemonox-CT) with the activated clotting time (ACT) and anti-Xa activity to monitor the anticoagulation effects of enoxaparin and dalteparin during percutaneous coronary intervention (PCI).

METHODS

A total of 90 patients undergoing cardiac catheterization were assigned to intravenous (IV) enoxaparin 0.5 mg/kg, dalteparin 50 international units/kg or unfractionated heparin (UFH) 50 units/kg. We measured Hemonox-CT, ACT and plasma anti-Xa levels after serial sampling.

RESULTS

Baseline Hemonox-CT was similar in the enoxaparin (68 +/- 9 sec) and dalteparin (68 +/- 7 sec) groups with no detectable anti-Xa activity at baseline. Minutes after IV administration of enoxaparin and dalteparin, the mean Hemonox-CT increased to 171 +/- 60 sec and 214 +/- 70 sec for both groups, respectively. UFH induced a higher Hemonox-CT response (800 +/- 243 sec). At all time points, Hemonox-CT was higher than the ACT. Peak Hemonox-CT was associated with a therapeutic anti-Xa activity ranging from 0.50 to 1.35 U/ml (mean 0.89 U/ml) for the enoxaparin group and 0.69 to 1.48 U/ml (mean 0.91 U/ml) for the dalteparin group. After reaching peak levels, there was a gradual and parallel decline in Hemonox-CT and anti-Xa activity. The enoxaparin and dalteparin-treated patients successfully underwent PCI without major hemorrhagic complications.

CONCLUSIONS

The Hemonox-CT has better sensitivity to both enoxaparin and dalteparin than does the ACT. Also, Hemonox-CT correlates with anti-Xa activity after IV administration. Hemonox-CT may become an important tool to monitor the anticoagulation effects of low-molecular weight heparin during PCI. Additional studies are needed to determine the target Hemonox-CT.

Activated clotting time (ACT)-guided intravenous dalteparin dosing during percutaneous coronary intervention

BACKGROUND

The activated clotting time (ACT) has been reported to be sensitive to the anticoagulant activity of the low-molecular weight heparin dalteparin following intravenous (IV) administration.

OBJECTIVE

To evaluate the feasibility of an ACT-guided dalteparin dose adjustment strategy during percutaneous coronary intervention (PCI).

METHODS

This was a retrospective study of 104 consecutive patients who underwent PCI using an ACT-guided strategy of IV dalteparin. All patients received an initial IV bolus of 50 IU/kg of dalteparin. The minimum target ACT was 175 seconds for patients who received glycoprotein IIb/IIIa inhibitors and 200 seconds for patients who did not. Patients who did not achieve the target ACT after the initial 50 IU/kg were given supplemental boluses of dalteparin based on the assumption that for every additional 10 IU/kg of dalteparin, the ACT will rise by approximately 10 seconds.

RESULTS

After the initial bolus of dalteparin, the mean baseline ACT rose from 138 +/- 41 seconds to 235 +/- 78 seconds. In the 36 patients (35% of the study population) who required a mean supplemental dose of 14 +/- 6 IU/kg/kg, the mean ACT after the supplemental dose was 239 +/- 79 seconds. The composite endpoint of in-hospital death, target vessel revascularization (TVR) and myocardial infarction (MI) was 5.8%. Major and minor bleeding rates were 1% each. The composite incidence of death/MI/TVR was comparable to, and the bleeding complications were lower than, those achieved in the SYNERGY and STEEPLE trials.

CONCLUSION

ACT-guided dose adjustment of intravenously administered dalteparin during PCI appears to constitute a feasible strategy.

Effect of dalteparin and radiation on survival and thromboembolic events in glioblastoma multiforme: a phase II ECOG trial

Laboratory and clinical studies support the concept that heparins, particularly the low molecular component, may serve as an inhibitor of angiogenesis, providing anti-neoplastic effects. Further, treatment with low molecular weight heparin (LMWH) may provide prophylaxis for thromboembolic events (TEE), in glioblastoma (GBM) patients. Dalteparin (5,000 U sub-Q daily) was given with and after conventional radiotherapy to newly diagnosed GBM patients. Forty-five patients were accrued between 5/02 and 9/04; 3 were ineligible. At time of progression, patients could continue dalteparin in addition to standard regimens. Pretreatment characteristics included: median age 61 (range 26-78); ECOG Performance status: 0 = 38%, 1 = 57%, 2 = 5%; gross total resection 45%. There were no grade 3/4 bleeding or thrombocytopenic events, and no TEE occurred while on dalteparin. Median time on dalteparin was 6.3 months, median time to progression was 3.9 months; median survival was 11.9 months. There was no significant improvement in survival when compared to the RTOG GBM database (with various radiation/drug doublets including BCNU) using recursive partitioning analysis. Historically the incidence of TEE in GBM patients is approximately 30%. As this study suggests dalteparin reduces the incidence of TEE, and does not have significant overlapping toxicities with most other drugs; its testing in a combined modality approach with other medications may be warranted in future trials.

[Pregnancy and childbirth in a patient with a spinal cord lesion]

A 37-year-old woman with a spinal cord lesion at the level of TvIII due to a car-accident, became pregnant. She had posttraumatic syringomyely at Cv-TvIII, for which she underwent syringo-arachnoidal drainage. At approximately six weeks of amenorrhoea she presented at the emergency room with vaginal bleeding. She was treated with dalteparine 5000 IU once daily given by intramuscular injection until 6 weeks post partum. Weekly urine checks were advised. At 36 6/7 weeks of pregnancy, the patient was admitted to hospital for daily cardiotocography and 4-hourly contraction monitoring. After spontaneous rupture of the membranes she went into labour and had a vaginal delivery of a son weighing 3320 g. His Apgar score was 6 after 1 min and 9 after 5 min; arterial pH was 7.31. For three months after giving birth she received specialist care at home as well as help and counselling from a rehabilitation centre. In pregnant women with a spinal cord lesion, special attention should be paid to urinary tract infections, pressure areas, anaemia and thrombo-embolic symptoms. During partus, cardiotocographic monitoring should be carried out, also in patients with TvI-Tx lesions regularly from 36 weeks. In pregnant women with lesions from TvI, medical attendants should be aware of the possibility of autonomous dysreflection. Epidural anaesthesia should be administered and episiotomy or rupture avoided. Post partum, the bladder should always be completely emptied and pressure areas and signs ofthrombo-embolic complications monitored. A urological bladder function consultation should be requested, and, ifepisiotomy or rupture does occur, extra care should be taken to avoid infection. The ergonomic situation at home should be evaluated to ensure that any ergonomic changes necessary for the care of the patient and her newborn, take place in time.

Acute generalized exanthematous pustulosis from dalteparin

Heparins are widely used for the prophylaxis and treatment of venous thromboembolism. Several types of immunologically mediated reactions to heparins are reported, among them delayed-type hypersensitivity reactions with erythematous, infiltrated itchy plaques at injection sites. We describe a female patient, whose localized reaction from dalteparin was followed by a generalized rash presenting as acute generalized exanthematous pustulosis. Subcutaneous provocation testing showed cross-reactions to enoxaparin, certoparin, reviparin, nadroparin, danaparoid, fondaparinux, but not to pentosan polysulfate. The danaparoid and in a lesser extent the nadroparin patch showed pustules. Within the next day, a generalized rash developed. The upper aspect of her trunk was highly affected and showed discrete pustules. Despite the fact that low molecular-weight heparins are widely prescribed, this is, to our knowledge, the first observation of a pustular drug eruption attributable to this class of substances.

A pilot study of central venous catheter survival in cancer patients using low-molecular-weight heparin (dalteparin) and warfarin without catheter removal for the treatment of upper extremity deep vein thrombosis (The Catheter Study)

BACKGROUND

Central venous catheters in patients with cancer are associated with development of deep vein thrombosis (DVT); however, there is no accepted standard treatment.

OBJECTIVES

To assess the safety and effectiveness of a management strategy for central venous catheter-related DVT in cancer patients consisting of dalteparin and warfarin without the need for line removal.

PATIENTS/METHODS

Patients older than 18 years of age with an active malignancy and who had symptomatic, acute, objectively documented UEDVT were eligible. Patients were treated with dalteparin 200 IU kg(-1) per day for 5-7 days and warfarin with a target International Normalized Ratio of 2.0-3.0. Patients were followed for 3 months for recurrent venous thromboembolism, major hemorrhage and survival of the central venous catheter.

RESULTS

There were 74 patients (48 males). The average age was 58 years. There were no episodes of recurrent venous thromboembolism and three (4%) major bleeds. No lines were removed because of infusion failure or recurrence/extension of DVT.

CONCLUSION

Treatment of UEDVTs secondary to central catheters in cancer patients with standard dalteparin/warfarin can allow the central line to remain in situ with little risk of line failure or recurrence/extension of the DVT.

The effect of dalteparin on coagulation activation during pregnancy in women with thrombophilia. A randomized trial

Low-molecular-weight heparin (LMWH) is increasingly being used for prophylaxis of venous thromboembolism (VTE) and prevention of pregnancy associated morbidity in pregnant women with thrombophilia. We sought to determine if the administration of prophylactic doses of LMWH downregulates coagulation activation in high risk pregnant women with thrombophilia. This sub-study was planned as part of a randomized open label controlled trial (Thrombophilia in Pregnancy Prophylaxis Study [TIPPS]) in which patients at high risk of pregnancy complications with confirmed thrombophilia are randomized to receive either dalteparin (5,000 units/day until 20 weeks then 5,000 units q12h until 37 weeks or onset of labor) or no treatment. Blood samples were collected at baseline, day 7-9 (after starting study drug), week 20 (before increasing study drug), week 36 (prior to stopping study drug) and at the time of admission to the labor and delivery unit. Samples were not drawn at fixed times in relation to drug injection. These samples were analyzed for levels of thrombin-antithrombin complexes (TAT), prothrombin fragments 1 + 2 (F1.2), D-dimer and anti-Xa activity. Generalized linear mixed models were used for statistical analysis and model results were controlled for age, smoking status, type of thrombophilia and predisposing risk factors. The effect of dalteparin on TAT levels was defined as the primary outcome. Of 198 patients eligible, 114 were enrolled in TIPPS. Ninety-one were eligible for the TIPPS coagulation activation sub-study and randomized. Thirty-nine patients were analyzed in the treatment group (dalteparin) and 46 patients in the control group (no intervention). Levels of coagulation activation factors F1.2, TAT and D-dimer increased significantly throughout pregnancy in both groups (p < 0.0001). Dalteparin prophylaxis resulted in a significant increase in anti-Xa activity through pregnancy (p < 0.0001) compared to controls. Dalteparin had no significant effects on the levels of TAT, F1.2 and D-dimer throughout pregnancy in thrombophilic women. A post-hoc Monte Carlo power analysis revealed that our study had 100% and 88% power to detect reductions in TAT values on treatment of 50% and 25%, respectively. Prophylaxis with dalteparin at doses used in this study did not reduce coagulation activation in high risk thrombophilic women during pregnancy.

Dalteparin Versus Enoxaparin for Venous Thromboembolism Prophylaxis in Acute Spinal Cord Injury and Major Orthopedic Trauma Patients: ???DETECT??? Trial

BACKGROUND

To compare the impact of switching from enoxaparin 30 mg subcutaneously (SC) twice daily to dalteparin 5,000 units SC once daily for venous thromboembolism (VTE) prophylaxis in critically-ill major orthopedic trauma and/or acute spinal cord injury (SCI) patients.

METHODS

DETECT was a retrospective, cohort study at a tertiary care referral teaching center-phase 1 from December 1, 2002 to November 30, 2003 (enoxaparin); and phase 2 from January 1, 2004 to December 31, 2004 (dalteparin). Major orthopedic trauma patients with pelvic, femoral shaft, or complex lower extremity fractures, and/or acute SCI patients admitted to the intensive care unit and who received a low-molecular-weight heparin (LMWH) for VTE prophylaxis were included.

RESULTS

DETECT reviewed 135 patients (63 enoxaparin, 72 dalteparin), with similar baseline demographics, clinical characteristics, injuries, severity of illness, and risk factors for VTE. Clinically symptomatic proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) rates were 1.6% with enoxaparin and 9.7% with dalteparin (p=0.103, absolute risk increase [ARI] of 8.1% [-0.6% to 15.6%]), with no differences in major bleeding (6.4% versus 6.9%) or minor bleeding (64% versus 69%), or mortality (4.8% versus 6.9%). Switching from enoxaparin to dalteparin was associated with $12,485 (CAD) in LMWH acquisition cost savings.

CONCLUSIONS

DETECT raises the hypothesis that dalteparin 5,000 units SC daily may not be clinically noninferior to enoxaparin 30 mg SC twice daily for VTE prophylaxis in this high-risk population. Until an adequately-powered, prospective noninferiority trial is performed, enoxaparin is supported by level 1 evidence and should be the prophylactic agent of choice.

Utility of once-daily dose of low-molecular-weight heparin to prevent venous thromboembolism in multisystem trauma patients

INTRODUCTION

Venous thromboembolism is a preventable cause of death in the severely injured patient. Low-molecular-weight heparins (LMWHs) have been recommended as effective, safe prophylactic agents. However, LMWH use remains controversial in patients at risk for bleeding, those with traumatic brain injury, and those undergoing multiple invasive or operative procedures. We hypothesized that a protocol utilizing once-daily LMWH prophylaxis in high-risk trauma patients, regardless of the need for invasive procedures, is feasible, safe, and effective.

METHODS

From August 1998 to August 2000, all patients admitted to our American College of Surgeons-verified Level I trauma facility following injury were evaluated for deep venous thrombosis (DVT) risk and prospectively followed. Patients at high risk for DVT, including those with stable intracranial injuries, were placed on our institutional protocol and prospectively followed. Patients on the protocol received daily injections of the LMWH, dalteparin; DVT screening was performed with duplex ultrasonography within 48 hours of admission and after 7 to 10 days after injury. Regimen compliance, bleeding complications, DVT rates, and pulmonary embolus (PE) rates were analyzed.

RESULTS

During the 2-year study period, 6247 trauma patients were admitted; 743 were considered at high risk for DVT. Most of the patients were men (72%), with a mean age of 38.7 years (range 15-89 years) and a mean injury severity score (ISS) of 19.5. Compliance with the daily regimen was maintained in 74% of patients. DVT was detected in 3.9% and PE in 0.8%. The wound complications rate was 2.7%, and the need for unexplained transfusions was 3%. There were no exacerbations of head injury following dalteparin initiation due to bleeding. There were 16 patient deaths; none was caused by PE or late hemorrhage.

CONCLUSIONS

Once-daily dosing of prophylactic LMWH dalteparin is feasible, safe, and effective in high-risk trauma patients. Our protocol allows one to "operate through" systemic prophylaxis and ensures timely prophylaxis for brain-injured and multisystem trauma patients.