The efficacy of weight-based enoxaparin dosing for venous thromboembolism prophylaxis in trauma patients: A systematic review and meta-analysis

Abstract

BACKGROUND:Trauma patients are at high risk of developing venous thromboembolism (VTE), and standard dosing enoxaparin regimens may be inadequate for prophylaxis. This meta-analysis was performed to clarify the efficacy of alternative dosing regimens for VTE prophylaxis in this high-risk group. The objective of this systematic review was to review the evidence regarding weight-based dosing of enoxaparin for VTE prophylaxis in trauma patients. METHODS:A systematic database search was undertaken for studies comparing standard versus weight-based dosing of enoxaparin for VTE prophylaxis in adult trauma patients, 18 years or older. The primary outcome was the achievement of anti-factor Xa (AFXa) levels within the prophylactic range. Secondary outcomes included subprophylactic AFXa levels, supraprophylactic AFXa levels, VTE incidence, and bleeding events. Meta-analysis was conducted using both fixed-and random-effects models, and presented as odds ratios, risk ratios (RRs), and risk differences (RDs) with 95% confidence intervals (CIs). RESULTS:Four cohort studies were eligible for inclusion. Compared with standard dosing, weight-based enoxaparin prophylaxis dosing was associated with increased odds of prophylactic AFXa levels (odds ratio, 5.85; 95% CI, 3.02-11.30; p < 0.00001) and reduced risk of subprophylactic AFXa levels (RR, 3.97; 95% CI, 3.02-5.22; p < 0.00001). Standard dosing was associated with a reduced risk of supratherapeutic AFXa levels (RR, 0.23; 95% CI, 0.11-0.50; p = 0.0002), but this was not associated with a difference in risk of bleeding events (RD, −0.00; 95% CI, −0.02 to 0.01; p = 0.55). There was no statistical difference in incidence VTE between the two groups (RD, 0.01; 95% CI, −0.02 to 0.03; p = 0.64). CONCLUSION:Compared with standard dosing, weight-based enoxaparin dosing regimens are associated with increased odds of prophylactic range AFXa levels. Further investigation is required to determine if this translates into improved VTE prophylaxis and reduced VTE incidence.

Multicenter study evaluating target attainment of anti‐Factor Xa levels using various enoxaparin prophylactic dosing practices in adult trauma patients

“…31 A meta-analysis found that weight-based dosing of enoxaparin for VTE prophylaxis was associated with increased odds of anti-Xa levels at goal, with no difference in bleeding or VTE events. 22 Most of the hospitals in our study used similar dosing strategies based upon weight, BMI, or a hybrid of both. In our study, 61% of initial peak anti-Xa levels were within our target range of 0.2-0.4 units/mL, with the BMI-based dosing group having the highest rate of suboptimal anti-Xa levels.…”

“…In a study describing implementation of an anti‐Xa monitoring protocol, 75% of patients had initial anti‐Xa level at goal using enoxaparin 30 mg twice daily in patients 50–100 kg and with BMI <40 kg/m 2 , or 40 mg twice daily in patients ≥100 kg or with BMI ≥40 kg/m 2 31 . A meta‐analysis found that weight‐based dosing of enoxaparin for VTE prophylaxis was associated with increased odds of anti‐Xa levels at goal, with no difference in bleeding or VTE events 22 . Most of the hospitals in our study used similar dosing strategies based upon weight, BMI, or a hybrid of both.…”

“…[11][12][13][14][15][16][17] Studies evaluating fixed enoxaparin dosing (30 mg twice daily) compared to patient-specific dosing based on total body weight (TBW) or body mass index (BMI) have demonstrated higher attainment of target prophylactic anti-Xa levels and decreased VTE rates with patient-specific dosing. 11,[18][19][20][21][22] Although it is clear that a fixed enoxaparin dose of 30 mg twice daily is suboptimal in most trauma patients, there is limited evidence to determine the best approach to patient-specific dosing for VTE prophylaxis. BMI and TBW methods are widely utilized but have not been compared in rigorous studies.…”

“…Protocolized dosing using anti‐Factor Xa (anti‐Xa) levels to measure the anticoagulant effect of enoxaparin and guide dose adjustments may be helpful for achieving target prophylactic anti‐Xa levels and is associated with reduced VTE rates 11–17 . Studies evaluating fixed enoxaparin dosing (30 mg twice daily) compared to patient‐specific dosing based on total body weight (TBW) or body mass index (BMI) have demonstrated higher attainment of target prophylactic anti‐Xa levels and decreased VTE rates with patient‐specific dosing 11,18–22 . Although it is clear that a fixed enoxaparin dose of 30 mg twice daily is suboptimal in most trauma patients, there is limited evidence to determine the best approach to patient‐specific dosing for VTE prophylaxis.…”

Comparison of Different Intervention Methods to Reduce the Incidence of Venous Thromboembolism: Study Protocol for a Cluster-Randomized, Crossover Trial

“…Compared with a xed dosage, a weight-based dosage may be more effective in reaching the expected anti-Xa level (9). Additionally, weight has been proven to be a key predictor of anti-Xa level (10). Thus, our study is designed to administer weight-based dosage of LMWH, instead of xed dosage as usual, to achieve better effect in preventing VTE.…”