Evaluation of a Treatment-Dose Enoxaparin Protocol for Patients With Obesity

Berger, Olivia; Sebaaly, Jamie; Crawford, Rachel; Rector, Katherine; Anderson, William E.

doi:10.1177/08971900211022300

Cited by 4 publications

(4 citation statements)

References 18 publications

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“…When compared to other studies, this study's initial anti-Xa distributions reflected a greater incidence of suboptimal anticoagulation than those seen when defining obesity as a BMI of greater than or equal to 40 kg/m 2 . 12,13 These previous studies identified a correlation between obesity and supratherapeutic anti-Xa levels, leading to an increased risk of bleeding events in their study population. With a median body mass index (BMI) of 35 kg/m 2 in the study cohort, these findings further corroborate the need for dose adjustments according to anti-Xa levels in the obese population.…”

Section: Discussionmentioning

confidence: 91%

Optimal Dosing of Enoxaparin in Critically Ill Patients with Venous Thromboembolism

Abdulla

Williams²,

Branan³

et al. 2023

Innov Pharm

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Background: Evidence suggests that goal anti-Xa levels are achieved in only 33% of critically ill patients receiving standard prophylactic enoxaparin dosing. There has been limited focus on the potential suboptimal anticoagulation effect on medical intensive care unit (MICU) patients receiving therapeutic enoxaparin dosing for venous thromboembolism (VTE). Methods: MICU patients receiving enoxaparin 1 mg/kg twice daily or 1.5 mg/kg daily for VTE treatment in a 350-bed community teaching hospital between 2013 and 2019 with at least one peak anti-Xa level measured were included. The primary outcome was the proportion who achieved therapeutic anti-Xa levels with standard dosing. Secondary outcomes included types of dose-adjustments required and the proportion requiring subsequent dose-adjustments. Descriptive statistics were presented for all outcomes. Results: Fifty-three patients were evaluated, including those receiving either twice-daily or once-daily standard therapeutic dosing. Optimal anti-Xa levels at first measurement were recorded after the initiation of enoxaparin in 26.4% (n=14) patients. Dose adjustments were required in 70.7% (n=29) of patients receiving twice-daily dosing and in 83.3% (n=10) receiving once-daily dosing (P=0.97) to appropriately increase or decrease the enoxaparin dose. By the third anti-Xa level measurement, 3 patients remained outside of the therapeutic range. Conclusions: Standard therapeutic enoxaparin dosing did not result in optimal anti-Xa levels for a majority of MICU patients regardless of dosing regimen used or patient specific factors. Future studies should identify patient factors associated with the requirement for higher or lower enoxaparin dosing.

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Section: Discussionmentioning

confidence: 91%

Optimal Dosing of Enoxaparin in Critically Ill Patients with Venous Thromboembolism

Abdulla

Williams²,

Branan³

et al. 2023

Innov Pharm

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“…28 Other studies in the obese population have demonstrated the need for reduced doses ranging from 0.7 to 0.8 mg/kg to obtain therapeutic anti-Xa levels. 28-31 In a study by Deal et al, 28 the 6 bleeding events had significantly higher anti-Xa levels (1.5 IU/ml vs 0.98 IU/ml; P = 0.07). A meta-analysis published by Liu et al 32 demonstrated a significantly lower bleeding rate in obese patients using a reduced-dosage strategy than with standard dosing (OR 0.30, 95% CI 0.10-0.89, P = 0.03).…”

Section: Discussionmentioning

confidence: 91%

“…Studies have also used varying definitions of obesity and included different degrees of obesity, making it difficult to compare results between studies. [29][30][31][32][33] While both weight and BMI cutoffs have been used in the literature to define obesity, our study is the first to show an increasing odds of supratherapeutic anti-Xa levels with each category of obesity. BMI may be a better identifier of patients with a higher percentage of adipose tissue than total body weight.…”

Section: Discussionmentioning

confidence: 99%

Risk Stratification for Supratherapeutic Peak Anti-Xa Levels in Adult Patients on Therapeutic Enoxaparin

Sheredy,

Stone,

Mostafavifar

et al. 2023

Ann Pharmacother

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Background: The American Society of Hematology Guidelines for the management of venous thromboembolism recommend against the use of anti-Xa monitoring for assessing enoxaparin dosing based on a low level of evidence associating supratherapeutic levels with an increased risk of bleeding. However, institutions still utilize anti-Xa levels in select patient populations with altered volume of distribution and/or excretion to monitor and adjust therapy. Objective: The primary objective of this study was to identify risk factors associated with supratherapeutic peak anti-Xa levels (≥1.10 IU/mL) for patients receiving therapeutic enoxaparin. Methods: This was a retrospective single-center study performed at an academic tertiary care hospital. Patients who received enoxaparin at 1 mg/kg twice daily and peak anti-Xa monitoring were separated into supratherapeutic and therapeutic/subtherapeutic cohorts. Results: A total of 436 patients were screened, and 215 were included, with a mean age of 62 years. There were 108 in the therapeutic/subtherapeutic cohort and 107 in the supratherapeutic cohort. Acute kidney injury (AKI), body mass index (BMI), weight, female sex, intensive care unit (ICU) service, Sequential Organ Failure Assessment (SOFA) score ≥4, and creatinine clearance at the time of peak anti-Xa level collection were associated with supratherapeutic anti-Xa levels in univariate models. Adjusted logistic regression models were created and identified BMI in the 30 to 34.9 kg/m2 (odds ratio [OR] 4.35; 95% confidence interval [CI] 1.70-11.13, P < 0.005) and ≥35 kg/m2 (OR 6.75; 95% CI 3.05-14.94, P < 0.005) and AKI (OR 2.62; 95% CI 1.04-6.62, P = 0.042) as significant risk factors for supratherapeutic anti-Xa levels. Conclusion and Relevance: Our study identified BMI ≥ 30 kg/m2, AKI, female sex, ICU service, SOFA score ≥4, and creatinine clearance as risk factors for supratherapeutic anti-Xa levels in patients receiving 1 mg/kg twice daily dosing of enoxaparin. Further research should be done to provide evidence for the association between anti-Xa levels and bleeding risk.

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“…In a large-scale retrospective cohort study, despite receiving chemoprophylaxis, critically ill obese patients had a significantly higher incidence of VTE than nonobese patients ( 3 ). Moreover, for the treatment of obese VTE patients, some researchers have proposed a reduced dosage of LMWH, instead of 1 mg/kg twice daily ( 14 , 15 ). Higher anti-Xa exposure at the same dosage may lead to a higher incidence of supratherapeutic anti-Xa levels.…”

Section: Introductionmentioning

confidence: 99%

Strategies involving low-molecular-weight heparin for the treatment and prevention of venous thromboembolism in patients with obesity: A systematic review and meta-analysis

Liu

Qiao

et al. 2023

Front. Endocrinol.

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IntroductionRecent studies have indicated that the dosage of LMWH in patients with specific weights may be controversial. Therefore, we conducted a meta-analysis to explore an appropriate dosage of LMWH for the prevention and treatment of venous thromboembolism (VTE) in patients with obesity.Materials and methodsWe searched the PubMed, EMBASE, and Cochrane Library databases up to July 23, 2022. Study selection, bias analysis, and information extraction were performed by three independent reviewers. The occurrence or recurrence of VTE and bleeding events were the primary outcomes we assessed.ResultsEleven studies (a total of 6266 patients) were included in the prevention group, and 6 studies (a total of 3225 patients) were included in the treatment group. For VTE prophylaxis, compared with the standard-dosage group, the high-dosage group had a lower incidence of VTE (OR: 0.47, 95% CI: 0.27-0.82, P=0.007) and a similar incidence of bleeding events (OR: 0.86, 95% CI: 0.69-1.08, P=0.020). For VTE therapy, compared to the standard-dosage group, the reduced-dosage group had a similar incidence of VTE recurrence (OR: 0.86, 95% CI: 0.11-6.84, P=0.89) but a lower incidence of bleeding events (OR: 0.30, 95% CI: 0.10-0.89, P=0.03).ConclusionIn patients with obesity, increasing the dosage of LMWH is a more appropriate option for the prevention of VTE. Due to the limited evidence, reducing the therapeutic dosage of LMWH requires careful consideration. Larger-scale, well-designed randomized controlled trials are necessary.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?, identifier ID=CRD42022298128.

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Evaluation of a Treatment-Dose Enoxaparin Protocol for Patients With Obesity

Cited by 4 publications

References 18 publications

Optimal Dosing of Enoxaparin in Critically Ill Patients with Venous Thromboembolism

Optimal Dosing of Enoxaparin in Critically Ill Patients with Venous Thromboembolism

Risk Stratification for Supratherapeutic Peak Anti-Xa Levels in Adult Patients on Therapeutic Enoxaparin

Strategies involving low-molecular-weight heparin for the treatment and prevention of venous thromboembolism in patients with obesity: A systematic review and meta-analysis

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