Utility of anti-factor Xa monitoring in surgical patients receiving prophylactic doses of enoxaparin for venous thromboembolism prophylaxis

Pannucci, Christopher J.; Prazak, Ann Marie; Scheefer, Melody

doi:10.1016/j.amjsurg.2016.08.010

Cited by 44 publications

(37 citation statements)

References 52 publications

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“…As a result, several studies published in recent years have used anti-Xa level monitoring to demonstrate that standard enoxaparin prophylactic dosing regimens frequently fail to achieve adequate therapeutic levels in various patient populations and that weight-based dosing regimens, with dose adjustment based on anti-Xa levels, may be more effective. [9][10][11] In fact, the American College of Chest Physicians has previously recommended that anti-Xa level monitoring be used to guide dosing of LMWHs in patient populations that are known to be at risk of either overdosing or underdosing with traditional dosing strategies, such as neonates, children, pregnant patients, and patients with obesity or renal insufficiency. 12,13 At our institution, an anti-Xa assay takes approximately 10 minutes to perform after the sample is received in the laboratory, and a few years ago, we began using this test when deciding whether to proceed with a neuraxial procedure in a patient on treatment dose enoxaparin whose last dose was administered close to 24 hours before surgery.…”

Section: Discussionmentioning

confidence: 99%

Residual Enoxaparin Activity, Anti-Xa Levels, and Concerns About the American Society of Regional Anesthesia and Pain Medicine Anticoagulation Guidelines

Henshaw

Turner

Thompson

et al. 2017

Regional Anesthesia and Pain Medicine

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Currently, the American Society of Regional Anesthesia and Pain Medicine (ASRA) anticoagulation guidelines recommend that before the performance of a neuraxial procedure a minimum of 24 hours should elapse following a treatment dose of enoxaparin (1 mg/kg twice daily or 1.5 mg/kg once daily). The guidelines have since their inception also consistently recommended against the routine use of anti-Xa level monitoring for patients receiving enoxaparin. However, we noted in our clinical practice that anti-Xa levels were frequently still elevated despite patients meeting the time-based recommendation for treatment dose enoxaparin. To further investigate the possibility that residual anticoagulant activity may persist longer than 24 hours after a treatment dose of enoxaparin, we assessed anti-Xa level activity in patients presenting for elective surgery. Despite nearly universal compliance with ASRA's anticoagulation guidelines (1 sample was drawn at 23.25 hours), anti-Xa activity was found to be elevated in 11 of 19 patients. While 10 patients had an anti-Xa level within the peak prophylactic range (0.2-0.5 IU/mL), 1 patient's level was found to still be in the peak therapeutic range (0.5-1.0 IU/mL). These findings suggest that significant anticoagulant activity may persist longer than previously appreciated after the last treatment dose of enoxaparin and that the current time-based ASRA recommendation may not be conservative enough. Further research is needed to delineate the level of anti-Xa activity below which it is likely safe to proceed with a neuraxial procedure, but it may be time to reconsider the utility of anti-Xa level monitoring when it is available.

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Section: Discussionmentioning

confidence: 99%

Residual Enoxaparin Activity, Anti-Xa Levels, and Concerns About the American Society of Regional Anesthesia and Pain Medicine Anticoagulation Guidelines

Henshaw

Turner

Thompson

et al. 2017

Regional Anesthesia and Pain Medicine

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“…A multidisciplinary consensus was created for careful decision-making in prescribing anticoagulation in high IMPROVE bleeding score patients. Anti-factor-Xa Assay (Stago®) was systematically performed for anticoagulation monitoring and adjustment in obese patients (n = 12) and those with acute renal failure (n = 20) [8]. Platelet activity was also monitored in those found to have DVT despite therapeutic anti-factor-Xa activity, with Multiplate ® due to its possible role when interacting with endothelial cells in the development of thrombosis and micro thrombosis in organs and tissues other than lungs [9].…”

mentioning

confidence: 99%

Asymptomatic deep vein thrombosis in critically ill COVID-19 patients despite therapeutic levels of anti-Xa activity

Torres-Machorro

Anguiano-Álvarez

Grimaldo-Gómez

et al. 2020

Thrombosis Research

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“…Goal peak aFXa levels are 0.2–0.4 IU/mL for twice daily dosing; this range has been shown to maximize VTE risk reduction while minimizing bleeding risk. 30,31,36,39,43,51 Patients have real-time aFXa-guided enoxaparin dose adjustment per Figure 5 performed by IDS Pharmacy; this will occur based on the peak steady-state aFXa level drawn 36 hours after surgery.…”

Section: Methodsmentioning

confidence: 99%

Double-Blind Randomized Clinical Trial to Examine the Pharmacokinetic and Clinical Impacts of Fixed Dose versus Weight-based Enoxaparin Prophylaxis: A Methodologic Description of the FIxed or Variable Enoxaparin (FIVE) Trial

Pannucci

Fleming

Bertolaccini

et al. 2019

Plastic and Reconstructive Surgery - Global Open

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Venous thromboembolism is an important patient safety in plastic surgery, and multiple clinical trials in the past 10 years have provided increased understanding of the risks and benefits of venous thromboembolism prevention strategies. This paper provides an exhaustive discussion of the rationale behind and methodology for an in progress randomized double-blind clinical trial in plastic surgery inpatients, in which the 2 study arms are enoxaparin 40 mg twice daily and enoxaparin 0.5 mg/kg twice daily. The trial’s primary aims are to: (1) demonstrate whether enoxaparin 0.5 mg/kg twice daily is superior to enoxaparin 40 mg twice daily for the pharmacokinetic endpoint of overanticoagulation (anti-Factor Xa > 0.4 IU/mL) and (2) demonstrate whether enoxaparin 0.5 mg/kg twice daily is not inferior to enoxaparin 40 mg twice daily for the pharmacokinetic endpoint of underanticoagulation (anti-Factor Xa < 0.2 IU/mL). The results of this trial will provide Level I evidence to help guide plastic surgeon’s choice of postoperative prophylactic anticoagulation.

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Utility of anti-factor Xa monitoring in surgical patients receiving prophylactic doses of enoxaparin for venous thromboembolism prophylaxis

Cited by 44 publications

References 52 publications

Residual Enoxaparin Activity, Anti-Xa Levels, and Concerns About the American Society of Regional Anesthesia and Pain Medicine Anticoagulation Guidelines

Residual Enoxaparin Activity, Anti-Xa Levels, and Concerns About the American Society of Regional Anesthesia and Pain Medicine Anticoagulation Guidelines

Asymptomatic deep vein thrombosis in critically ill COVID-19 patients despite therapeutic levels of anti-Xa activity

Double-Blind Randomized Clinical Trial to Examine the Pharmacokinetic and Clinical Impacts of Fixed Dose versus Weight-based Enoxaparin Prophylaxis: A Methodologic Description of the FIxed or Variable Enoxaparin (FIVE) Trial

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