Subcutaneous Enoxaparin Once or Twice Daily Compared with Intravenous Unfractionated Heparin for Treatment of Venous Thromboembolic Disease

Merli, Geno J.; Spiro, Theodore E.; Olsson, Carl; Abildgaard, Ulrich; Davidson, Bruce L.; Eldor, Amiram; Elias, Darlene J.; Grigg, Andrew; Musset, D.; Rodgers, George M.; Trowbridge, Arthur A.; Yusen, Roger D.; Zawilska, Krystyna

doi:10.7326/0003-4819-134-3-200102060-00009

Cited by 339 publications

(162 citation statements)

References 36 publications

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“…In this cohort of postarthroplasty patients, the incidence of major bleeding complications (10%) was substantially higher than the rates reported for nonsurgical patients, which are 0% to 5% [5,20,22,35]. This difference highlights the unique risks inherent to anticoagulation treatment in patients who have undergone procedures, which include substantial soft tissue dissection and osteotomies.…”

Section: Discussionmentioning

confidence: 63%

High Incidence of Complications From Enoxaparin Treatment After Arthroplasty

Neviaser

Chang

Lyman

et al. 2010

Clinical Orthopaedics &Amp; Related Research

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Pulmonary embolism (PE) complicates 1% to 10% of total joint arthroplasties and generally requires immediate anticoagulation. Low-molecular-weight heparins have supplanted unfractionated heparin as the treatment of choice for PE and hold a 1A recommendation from the American College of Chest Physicians for this indication. However, the complications of enoxaparin treatment begun in close proximity to arthroplasty surgery are not well described. We examined the records of 135 patients who underwent total joint arthroplasty, experienced an in-hospital PE, and received treatment with enoxaparin at therapeutic doses (1 mg/kg body weight). The type and frequency of complications were determined and classified as major or minor. Twenty-seven percent of patients experienced minor complications and 10% experienced major complications. The incidence of major bleeding was substantially higher than rates reported for nonsurgical patients. The overall complication rate of enoxaparin treatment is similar to the rate of complications reported for unfractionated heparin treatment in this setting, but the complications are less severe.

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Section: Discussionmentioning

confidence: 63%

High Incidence of Complications From Enoxaparin Treatment After Arthroplasty

Neviaser

Chang

Lyman

et al. 2010

Clinical Orthopaedics &Amp; Related Research

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“…Two articles did report the cancer subgroups data. 12,13 Three other articles [14][15][16] had follow-up publications reporting the cancer subgroup data. [17][18][19][20] We contacted the authors of the remaining 19 articles to request cancer subgroup data: One author provided us with the data 21 ; another author indicated that the data were not available anymore 22 ; we used the cancer subgroup data for 7 articles, 23-29 because they were reported in 2 published systematic reviews 5,8 ; and we were not able to obtain any outcome data for the remaining studies.…”

Section: Data Synthesis and Analysismentioning

confidence: 99%

“…Patients with cancer, as noted earlier, constituted subgroups in all studies that were included. [12][13][14][15][16]21,[23][24][25][26][27][28][29] The 13 studies recruited a total of 1016 patients with cancer and 4797 patients without cancer. None of the studies specified the type(s) of cancer of participants.…”

Section: Data Synthesis and Analysismentioning

confidence: 99%

Anticoagulation for the initial treatment of venous thromboembolism in patients with cancer

Akl

Rohilla

Barba³

et al. 2008

Cancer

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BACKGROUND.The authors compared the relative efficacy and safety of low‐ molecular‐weight heparin (LMWH) and unfractionated heparin (UFH) for the initial treatment of venous thromboembolism (VTE) between patients with and without cancer.METHODS.By using Cochrane methodology for systematic reviews, separate meta‐analyses were conducted for subgroups of patients with and without cancer, and relative risks (RRs) were compared for statistical significance. The methodologic quality for each outcome was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation approach.RESULTS.LMWH reduced mortality significantly compared with UFH in patients with cancer (RR of 0.71; 95% confidence interval [95% CI], 0.52‐0.98 [moderate‐quality evidence]) but not in patients without cancer (RR of 0.97; 95% CI, 0.65‐1.46 [low‐quality evidence]). However, the difference in the RR for the 2 subgroups did not reach statistical significance (P = .113). The difference between LMWH and UFH in the effect on recurrent VTE was not statistically significant in the subgroup with cancer (RR of 0.78; 95% CI, 0.29‐2.08 [low‐quality evidence]), in the subgroup without cancer (RR of 0.94; 95% CI, 0.60‐1.46 [low‐quality evidence]), or between the 2 subgroups (P = .367). No data were available for bleeding outcomes, thrombocytopenia, or postphlebitic syndrome.CONCLUSIONS.The current results indicated that LMWH most likely is superior to UFH in reducing mortality in the initial treatment of VTE for patients with cancer. There is a need for more and better designed trials to confirm these findings. Cancer 2008. © 2008 American Cancer Society.

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“…Thus, the increased risks of major bleeding during anticoagulation in fragile patients could be explained, at least in part, by these other drugs that might have potentiated the effect of the anticoagulant therapy. The similar risk for bleeding than for VTE recurrences in VTE patients weighing ≤50 kg has not been consistently reported 26, 27, 28. These findings suggest the potential benefit of tailored therapy for VTE according to clinical characteristics of the patients and warrant external validation.…”

Section: Discussionmentioning

confidence: 85%

Clinical outcomes during anticoagulant therapy in fragile patients with venous thromboembolism

Moustafa

Giorgi‐Pierfranceschi²,

Micco

et al. 2017

Research and Practice in Thrombosis and Haemostasis

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Essentials Recent randomized trials suggested fewer bleeding events in fragile patients with VTE receiving DOACs.The frequency, clinical characteristics and outcome of these patients have not been reported in real life.Fragile patients with VTE had a higher risk for major bleeding or death and a lower risk for recurrences than non‐fragile. BackgroundSubgroup analyses from randomized trials suggested favorable results for the direct oral anticoagulants in fragile patients with venous thromboembolism (VTE). The frequency and natural history of fragile patients with VTE have not been studied yet.ObjectivesTo compare the clinical characteristics, treatment and outcomes during the first 3 months of anticoagulation in fragile vs non‐fragile patients with VTE.MethodsRetrospective study using consecutive patients enrolled in the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry. Fragile patients were defined as those having age ≥75 years, creatinine clearance (CrCl) levels ≤50 mL/min, and/or body weight ≤50 kg.ResultsFrom January 2013 to October 2016, 15 079 patients were recruited. Of these, 6260 (42%) were fragile: 37% were aged ≥75 years, 20% had CrCl levels ≤50 mL/min, and 3.6% weighed ≤50 kg. During the first 3 months of anticoagulant therapy, fragile patients had a lower risk of VTE recurrences (0.78% vs 1.4%; adjusted odds ratio [OR]: 0.52; 95% confidence intervals [CI]: 0.37‐0.74) and a higher risk of major bleeding (2.6% vs 1.4%; adjusted OR: 1.41; 95% CI: 1.10‐1.80), gastrointestinal bleeding (0.86% vs 0.35%; adjusted OR: 1.84; 95% CI: 1.16‐2.92), haematoma (0.51% vs 0.07%; adjusted OR: 5.05; 95% CI: 2.05‐12.4), all‐cause death (9.2% vs 3.5%; adjusted OR: 2.02; 95% CI: 1.75‐2.33), or fatal PE (0.85% vs 0.35%; adjusted OR: 1.77; 95% CI: 1.10‐2.85) than the non‐fragile.ConclusionsIn real life, 42% of VTE patients were fragile. During anticoagulation, they had fewer VTE recurrences and more major bleeding events than the non‐fragile.

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Subcutaneous Enoxaparin Once or Twice Daily Compared with Intravenous Unfractionated Heparin for Treatment of Venous Thromboembolic Disease

Abstract: Subcutaneous enoxaparin once or twice daily is as effective and safe as dose-adjusted, continuously infused unfractionated heparin in the prevention of recurrent symptomatic venous thromboembolic disease.

Cited by 339 publications

References 36 publications

High Incidence of Complications From Enoxaparin Treatment After Arthroplasty

High Incidence of Complications From Enoxaparin Treatment After Arthroplasty

Anticoagulation for the initial treatment of venous thromboembolism in patients with cancer

Clinical outcomes during anticoagulant therapy in fragile patients with venous thromboembolism

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