Subcutaneous Low-Molecular-Weight Heparin Compared With Continuous Intravenous Heparin in the Treatment of Proximal-Vein Thrombosis

Hull, Russell D.; Raskob, Gary E.; Pineo, Graham F.; Green, David; Trowbridge, Arthur A.; Elliott, Gregory; Lerner, Robert G.; Hall, J. C.; Sparling, Terence G.; Brettell, Herbert R.; Norton, John A.; Carter, Cedric J.; George, R; Merli, Geno J.; Ward, John; Mayo, Warren; Rosenbloom, David; Brant, Rollin

doi:10.1097/00006254-199209000-00010

Cited by 146 publications

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“…Previous studies have established the safety and efficacy of LMWH in the treatment of DVT (Prandoni et al, 1992;Koopman et al, 1996;Levine et al, 1996). Some have shown reduced mortality inpatients treated with LMWH, compared with UFH (Hull et al, 1992;Lensing et al, 1995). Although these studies included patients who received LMWH at home, most included inpatients treated with LMWH and the principal study aim was the safety and efficacy of LMWH compared to UFH rather than inpatient vs. outpatient treatment of DVT.…”

Section: Discussionmentioning

confidence: 99%

“…This requires frequent measurement of the activated partial thromboplastin time (APTT), necessitating prolonged hospital admission inpatients who may be otherwise well. The use of low molecular weight heparin (LMWH) in this clinical setting does not require monitoring and studies have shown it to be at least as safe and effective as intravenous unfractionated heparin when used both in the hospital and as outpatients (Hull et al, 1992;Prandoni et al, 1992;Koopman et al, 1996;Levine et al, 1996). Outpatient management of DVT is becoming increasingly common and studies have shown financial savings and patient preference but, to date, there have been few studies directly comparing this with conventional inpatient management using UFH (Lindmarker & Holmstrom, 1996;Harrison et al, 1998).…”

Section: Introductionmentioning

confidence: 99%

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Outpatient management of DVT using low molecular weight heparin and a hospital outreach service

Rymes

Lester

Connor

et al. 2002

Clinical &Amp; Laboratory Haematology

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In recent years there have been several studies comparing the efficacy and safety of low molecular weight (LMW) and unfractionated heparin for the treatment of deep venous thrombosis (DVT), showing them in the clinical trial setting to be equal in these regards. LMWH has the advantage of once daily subcutaneous injection and daily monitoring of levels is not usually required. This has led many centres to develop outpatient treatment strategies for these patients but evidence for the safety of this approach is scarce. In 1997 we developed a hospital outreach service for the treatment of patients with DVT and, in a retrospective study, have compared the outcome in 172 patients treated at home with 172 age, sex and thrombotic risk factor matched inpatients treated at our institution with unfractionated heparin. Five patients in the home treatment group suffered a haemorrhagic event, compared with six patients in the hospital group. One patient in the home treatment group had a recurrent DVT within the first 3 months of treatment; in the hospital-treated group, six patients had recurrent DVTs and nine developed pulmonary emboli. At 3 months, there were three deaths in the home treatment group, compared with five deaths in the hospital group. There was no difference in re-admission rate at 3 months: 23 in the home treatment group, 24 in the hospital-treated group. Average length of hospital stay for the home-treatment group was 2.1 days and 12 days for the hospital group. Warfarin control was found to be significantly better in those patients treated at home, and only 18% of patients treated in hospital received heparin according to hospital guidelines. In conclusion, outpatient management of patients with DVT using LMWH is as safe as hospitalization and continuous infusion of unfractionated heparin. The complication rate was lower in the home treatment group and, in particular, the incidence of recurrent thrombosis was significantly less in the home treatment group. In addition, warfarin control was better when managed by specialist nurses. Patients expressed a preference for home treatment.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Outpatient management of DVT using low molecular weight heparin and a hospital outreach service

Rymes

Lester

Connor

et al. 2002

Clinical &Amp; Laboratory Haematology

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“…All but two patients continued to receive dalteparin until they had two consecutive days with therapeutic oral anticoagulation measurements. The mean time to reach this goal was 6.7 days (range, [4][5][6][7][8][9][10][11][12][13][14]. In one patient daiteparin was stopped on Day 3, and in a second on Day 6, because of postoperative wound haematomas.…”

Section: Clinical Outcomesmentioning

confidence: 99%

Dalteparin for deep enous thrombosis: a hospital‐in‐the‐home program

Ting

Ziegenbein

Gan

et al. 1998

Medical Journal of Australia

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Objective: To assess the efficacy, safety and cost savings of home treatment of lower‐limb deep venous thrombosis (DVT). Setting: A hospital‐in‐the‐home treatment program. Patients: One hundred patients with acute lower limb DVT (53 proximal, 47 distal), and no contraindication to home treatment, were entered into the program from March 1995 to February 1997. Intervention: All patients received dalteparin, 200 units/kg subcutaneously, once daily for a minimum of five days, with commencement of oral anticoagulation (warfarin) on Day 2. Patients with proximal DVT had lung ventilation‐perfusion scans performed and were admitted to hospital for at least 24 hours. Patients with distal DVT were discharged directly to home treatment. Main outcome measures: Clinical responses and the results of sequential duplex ultrasonography at one week, one month, three months and six months. Results: There were no major, but six minor, bleeding complications, two of which led to dalteparin being withdrawn. Sixteen patients had lung ventilation‐perfusion scans showing a high probability of pulmonary embolism. All were asymptomatic, and follow‐up for at least three months showed no symptomatic thromboembolic events. Duplex ultrasonography showed progression of thrombosis in the first week of therapy in 13.2% of distal and 2.7% of proximal thromboses. Thereafter, distal DVT improved at a much greater rate than proximal DVT; after six months complete resolution was seen in 60.7% of distal and 18.5% of proximal thromboses, respectively. Cost saving was $197 per bed‐day equivalent compared with inpatient care. At 15 months' follow‐up, swelling and/or pain was reported by 49% of patients with distal DVT and 66% of those with proximal DVT. Conclusions: Once‐daily dalteparin therapy for DVT in a hospital‐in‐the‐home setting was safe, efficacious and cost effective. However, DVT resolution is a slow process, with significant long term morbidity.

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“…Similarly, the rate of major bleeding (0.3%) and overall mortality at 6 months (6.4%) are comparable with the Levine and Koopman studies. Furthermore it is of interest that these results in the ambulatory setting are comparable to a clinical trial in the hospital environment evaluating the same LMWH vs. UFH (Hull et al, 1992). Readmission rates for all causes over the 6-month period were also low.…”

Section: Discussionmentioning

confidence: 65%

“…The development of low molecular weight heparins (LMWHs) offers an alternative to UFH. LMWHs have been demonstrated to be at least as safe and effective as UFH in the initial management of DVT (Hull et al, 1992;Siragusa et al, 1996). In addition, LMWHs are administered by subcutaneous injection, do not require laboratory coagulation monitoring and therefore allow patients to be treated in the outpatient or ambulatory setting (Koopman et al, 1996;Levine et al, 1996).…”

Section: Introductionmentioning

confidence: 99%

The outcome of ambulatory DVT management using a multidisciplinary approach^*

Rose¹,

Bell²,

Green³

et al. 2001

Clinical &Amp; Laboratory Haematology

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Low molecular weight heparins (LMWHs) have been demonstrated to be at least as safe and effective as unfractionated heparin (UFH) in the initial management of deep vein thrombosis (DVT). However, the effectiveness of using LMWH in the ambulatory management of DVT in a 'real-life' setting has yet to be evaluated. This multicentre retrospective study involving 697 patients considers the outcome data of patients under- going ambulatory DVT treatment with tinzaparin (Innohep(R), Leo Pharmaceuticals, Risborough, Buckinghamshire, UK). During the 6 months following presentation, 17 (2.5%) patients had confirmed thromboembolic complications, of which 14 occurred subsequent to the initial LMWH treatment phase ('late'). There were no deaths in this group. Bleeding complications were reported in 23 (3.4%) patients, with 13 of these being classified as 'late'. Of these, two events were considered major resulting in hospitalization and death. Hospitalization for all causes was 6.8% (45 patients) with 32 patients being admitted for thromboembolic or bleeding complications. Overall mortality was 6.7%. These results compare favourably with published clinical trial data. This study demonstrates that ambulatory treatment of proven DVT with LMWH is both safe and effective.

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Subcutaneous Low-Molecular-Weight Heparin Compared With Continuous Intravenous Heparin in the Treatment of Proximal-Vein Thrombosis

Cited by 146 publications

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Outpatient management of DVT using low molecular weight heparin and a hospital outreach service

Outpatient management of DVT using low molecular weight heparin and a hospital outreach service

Dalteparin for deep enous thrombosis: a hospital‐in‐the‐home program

The outcome of ambulatory DVT management using a multidisciplinary approach^*

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Subcutaneous Low-Molecular-Weight Heparin Compared With Continuous Intravenous Heparin in the Treatment of Proximal-Vein Thrombosis

Cited by 146 publications

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Outpatient management of DVT using low molecular weight heparin and a hospital outreach service

Outpatient management of DVT using low molecular weight heparin and a hospital outreach service

Dalteparin for deep enous thrombosis: a hospital‐in‐the‐home program

The outcome of ambulatory DVT management using a multidisciplinary approach*

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The outcome of ambulatory DVT management using a multidisciplinary approach^*