Venous thromboembolism chemoprophylaxis regimens in trauma and surgery patients with obesity: A systematic review

Abstract

BACKGROUND Venous thromboembolism (VTE) continues to be a devastating source of morbidity and mortality in obese patients who suffer traumatic injuries or obese surgery patients. High incidence rates in VTE despite adherence to prevention protocols have stirred interest in new dosing regimens. The purpose of this study was to systematically review the literature and present the existing VTE chemoprophylaxis regimens for obese trauma and surgical patients in terms of efficacy and safety as measured by the incidence of VTE, anti-factor Xa levels, and the occurrence of bleeding events. METHODS An online search of seven literature databases including PubMed, Excerpta Medica Database, GoogleScholar, JAMA Network, CINAHL, Cochrane, and SAGE Journals was performed for original studies evaluating the safety and efficacy of VTE chemoprophylaxis dosing regimens according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The risk of bias was assessed using the Cochrane Risk of Bias Tool and the quality of evidence was determined using the GRADE Working Group criteria. RESULTS Of the 5,083 citations identified, 45 studies with 27,717 patients met inclusion criteria. In this group, six studies evaluated weight-based dosing regimens, four used a weight-stratified or weight-tiered strategy, five used a body mass index–stratified approach, 29 assessed fixed-dose regimens, and two used continuous infusions. The majority of the studies evaluated anti-factor Xa levels as their primary outcome rather than reduction in VTE. CONCLUSION Weight-based and high fixed-dose chemoprophylaxis regimens achieved target anti-Xa concentrations more frequently than standard fixed-dose regimens but were not associated with a reduction in VTE. Additionally, high fixed-dose approaches are associated with increased bleeding complications. Further evaluation with large randomized trials is warranted in trauma and surgery patients with obesity. LEVEL OF EVIDENCE Systematic review, level III.

Standard Fixed Enoxaparin Dosing for Venous Thromboembolism Prophylaxis Leads to Low Peak Anti-Factor Xa Levels in Both Head and Neck and Breast Free Flap Patients

“…36 A systematic review by Shaikh et al in obese trauma and surgery patients revealed that weight-based or high fixed-dosed regimens were more likely to achieve target afXa levels as compared with the classical fixed-dosed regimens. 34 The results of a recent double-blind randomized clinical trial studying fixed- versus weight-based variable enoxaparin (FIVE Trial) also provides supportive evidence for superior pharmacokinetics achieved by the weight-based dosing in the general plastic surgery population. 37 38 The weight-based approach also allowed for avoidance of overanticoagulation and had similar bleeding rates as the fixed-dose approach.…”

“…Indeed, obesity has previously been identified as a risk factor for VTE, 32 33 and standard fixed-dosing of enoxaparin does not achieve target afXa levels in obese patients. 34 35 When compared with fixed-dose regimens, weight-based dosing approaches were shown to be more effective. 36 A systematic review by Shaikh et al in obese trauma and surgery patients revealed that weight-based or high fixed-dosed regimens were more likely to achieve target afXa levels as compared with the classical fixed-dosed regimens.…”

Emergencies in obese patients: a narrative review

“…Due to the lack of sufficient data, however, there are no universally accepted VTE chemoprophylaxis recommendations in terms of the pharmacological agents, dosage, frequency, and duration for high-risk obese patients. The greatest consensus in the literature regards the use of enoxaparin at the dosage 0.5 mg/kg BID, which allows to achieve therapeutic antiXa levels, although it is not associated with a reduction in VTE, increasing the risk of bleeding complications [ 58 ].…”

Timing and Dose of Pharmacological Thromboprophylaxis in Adult Trauma Patients: Perceptions, Barriers, and Experience of Saudi Arabia Practicing Physicians

“…In our study, small percentage of the respondent indicated the use of anti-Xa level to guide enoxaparin prophylactic dose. While dose adjusting to achieve a target anti-Xa may be an option, its utility is limited as a therapeutic range has not been clearly defined and an association between anti-Xa and VTE incidence or bleeding events has not been demonstrated yet [58, 59].…”