Chronically anticoagulated patients who need surgery: Can low‐molecular‐weight heparins really be used to “bridge” patients instead of intravenous unfractionated heparin?

Abstract

Patients at high risk of arterial or venous thromboembolic events often receive chronic treatment with long-term oral anticoagulants such as warfarin. However, if these patients require an invasive procedure, they may require a temporary interruption of their warfarin therapy to minimize their bleeding risk during the procedure. As warfarin has a long half-life and an unpredictable pharmacokinetic profile, short-acting parenteral anticoagulants, such as unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH), may be of benefit in protecting the patient from thromboemboli while their warfarin dose is withheld. Such "bridging therapy" has traditionally been provided in-hospital with intravenous UFH; however, recent data have suggested that LMWH may be an effective alternative, with potential cost-savings due to the ability to provide bridging therapy in the outpatient setting.

A prospective multicenter observational study evaluating the risk of periendoscopic events in patients using anticoagulants: the Osaka GIANT Study

“…(3) We used intravenously administered unfractionated heparin because use of low-molecular-weight heparin (LMWH) is limited during hemodialysis and for the treatment of disseminated intravascular coagulation in our country, although use of LMWH is recommended in the ASGE and ESGE guidelines 5 10 . LMWH can be used in an outpatient setting 32 33 and the benefit of reduced duration of hospitalization may not be applicable to LMWH; however, using DOACs reduce heparin use and simplify the process of anticoagulant administration. (4) Most of the procedures were performed under the guidance of JGES guidelines, but some were performed by the decision of their own institution as some physicians were still concerned about gastrointestinal bleeding after endoscopic procedures with continuation of anticoagulants.…”

The Perioperative Management of Antithrombotic Therapies Using Enoxaparin

“…It has greater bioavailability and a more predictable dose response than unfractionated heparin (UFH) (571819). Jaffer et al (20) reported that the risk of major bleeding is strongly associated with the use of postoperative therapeutic doses of heparin/LMWH based on the analysis of practice patterns at 9 hospitals.…”

Bridging therapy and oral anticoagulation: current and future prospects

“…LMWH has a better pharmacokinetic profile, including higher bioavailability, a more predictable dose response, and a longer plasma half-life than UFH. Head-to-head comparisons between UFH and LMWH as bridging therapy in various patient groups reveal a low associated thromboembolic rate of approximately 1% for both UFH and LMWH, and trends towards less major bleeding with LMWH [21][22][23][24]. LMWH treatment was also associated with low arterial thromboembolic rates and less major bleeding when compared to UFH as bridging therapy in patients with prosthetic heart valves [7].…”