Weight-based enoxaparin dosing for venous thromboembolism prophylaxis in the obese trauma patient

Bickford, Annika; Majercik, Sarah; Bledsoe, Joseph; Smith, Katie; Johnston, Rob; Dickerson, Justin B.; White, Tom

doi:10.1016/j.amjsurg.2013.07.020

Cited by 78 publications

(69 citation statements)

References 18 publications

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“…Weight-based enoxaparin VTE prophylaxis dosing may also be reasonable in surgical and trauma patients despite the differences in pharmacokinetics if doses of 0.5 mg/kg every 12 hours are used, as these doses led to 86% and 91% attainment of goal aFXa levels, respectively. 4,9 Despite use of a lower dose, none of the patients in this study had a thrombotic event. The two bleeding events were not thought to be due to enoxaparin therapy given low Naranjo ADR scores, peak aFXa levels within goal, and other pre-existing risk factors for bleeding.…”

Section: Discussionmentioning

confidence: 79%

“…Of the weight‐based doses evaluated, 0.5 mg/kg/day allowed a greater proportion of patients to reach the goal range. Weight‐based enoxaparin VTE prophylaxis dosing may also be reasonable in surgical and trauma patients despite the differences in pharmacokinetics if doses of 0.5 mg/kg every 12 hours are used, as these doses led to 86% and 91% attainment of goal aFXa levels, respectively …”

Section: Discussionmentioning

confidence: 99%

“…Unlike VTE treatment dosing of enoxaparin, which is weight based (1 mg/kg subcutaneously every 12 hrs or 1.5 mg/kg daily), a fixed dose of 40 mg daily or 30 mg twice daily is recommended for VTE prophylaxis . However, fixed dosing may not be appropriate for all patients . In low‐weight patients, fixed prophylactic doses of enoxaparin may be close to or even exceed the weight‐based dosing recommended for VTE treatment, which may increase risk for bleeding.…”

mentioning

confidence: 99%

“…3 However, fixed dosing may not be appropriate for all patients. [4][5][6][7][8][9] In low-weight patients, fixed prophylactic doses of enoxaparin may be close to or even exceed the weight-based dosing recommended for VTE treatment, which may increase risk for bleeding. The 2018 American Society of Hematology (ASH) guidelines on VTE prophylaxis specifically mention the need for further research regarding the need for dose adjustment in underweight patients.…”

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confidence: 99%

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Enoxaparin Thromboprophylaxis Dosing and Anti–Factor Xa Levels in Low‐Weight Patients

et al. 2019

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Introduction Enoxaparin is a widely used anticoagulant to prevent venous thromboembolism (VTE). A fixed dose is recommended for VTE prophylaxis. However, fixed prophylactic doses of enoxaparin in low‐weight patients may be close to the weight‐based dosing recommended for VTE treatment. Objective To evaluate peak anti–factor Xa (aFXa) levels in low‐weight patients receiving enoxaparin for VTE prophylaxis. Methods Retrospective cohort of adult patients weighing < 55 kg who were hospitalized at Loma Linda University Medical Center between January 2008 and February 2017. All patients received enoxaparin for VTE prophylaxis with a peak aFXa level drawn. The primary endpoint was the proportion of patients achieving peak aFXa levels within the goal range of 0.2–0.5 unit/ml. Results Of 35 patients receiving enoxaparin for VTE prophylaxis with an appropriately timed peak aFXa level, 74% achieved goal peak aFXa levels and the median daily dose of enoxaparin was 30 mg. The mean weight was approximately 44 kg. No significant correlations between aFXa level and body mass index or body weight were found. Conclusion A lower dose of enoxaparin may be reasonable in low‐weight patients for VTE prophylaxis. There appears to be no safety concerns with reduced enoxaparin dosing in low‐weight patients. More robust data are needed to confirm these findings.

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Section: Discussionmentioning

confidence: 79%

Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Enoxaparin Thromboprophylaxis Dosing and Anti–Factor Xa Levels in Low‐Weight Patients

et al. 2019

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“…One prospective trial of 86 obese trauma patients (mean BMI 35.3 kg/m 2 ) showed that 86 % of patients achieved a steady-state anti-Xa within goal range (0.2-0.6 IU/mL) with this dosing strategy, and that the average anti-Xa level was 0.42 IU/mL [27]. This trial did report rates of thrombosis and found a correlation with weight, but this data was confounded by the fact that 16 of the 18 patients who developed a DVT did so before, or on the day of, enoxaparin initiation.…”

Section: Alternate Dosing Strategies In Morbid Obesitymentioning

confidence: 99%

Chemical prophylaxis to prevent venous thromboembolism in morbid obesity: literature review and dosing recommendations

Vandiver

Ritz

Lalama

2015

J Thromb Thrombolysis

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Pharmacologic prophylaxis of deep vein thrombosis and venous thromboembolism (VTE) is an important aspect of medical care, particularly in the inpatient setting. Low-molecular weight heparins, heparin, and fondaparinux are commonly used agents to prevent VTE, each of which has well established dosing regimens in patients with normal body mass index. Dosing of these medications in morbidly obese populations (BMI > 40 kg/m(2)) is not as clearly defined in guidelines. This article reviews published data to support specific dosing regimens and monitoring strategies of these agents in this population. The most validated parenteral agent to prevent VTE in morbidly obese hospitalized patients is enoxaparin, dosed at 40 mg subcutaneously (SC) twice daily. If unfractionated heparin is utilized for prophylaxis in morbidly obese patients, a dose of 7500 units SC three times daily should be considered. Monitoring of anti-factor Xa levels to guide prophylactic dosing is an option, although the utility of this lab test is limited, as target anti-Xa ranges for VTE prophylaxis have not been universally defined and trials have not shown a clear link between anti-factor Xa levels and bleeding or thrombotic events. Additional studies are needed to clearly define the most appropriate dosing strategies in patients with moderate obesity (BMI 35-40 mg/m(2)) and those with extreme obesity (BMI > 60 mg/m(2)).

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Assessment of BMI and Venous Thromboembolism Rates in Patients on Standard Chemoprophylaxis Regimens After Undergoing Free Tissue Transfer to the Head and Neck

Saadoun

Bengür

Moroni

et al. 2022

JAMA Otolaryngol Head Neck Surg

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ImportanceVenous thromboembolism (VTE) is a severe complication after free tissue transfer to the head and neck (H&amp;N). Enoxaparin 30 mg twice daily (BID) is a common regimen for chemoprophylaxis. However, differences in enoxaparin metabolism based on body weight may influence its efficacy and safety profile.ObjectiveTo assess the association between BMI and postoperative VTE and hematoma rates in patients treated with prophylactic enoxaparin 30 mg BID.Design, Setting, and ParticipantsThis was a retrospective review of a prospectively collected cohort from 2012 to 2022. Postoperative VTE, hematoma, and free flap pedicle thrombosis were recorded within 30 days of index surgery. The setting was a tertiary academic referral center. Participants included patients undergoing H&amp;N reconstruction with free flaps that received fixed-dose subcutaneous enoxaparin 30 mg BID postoperatively. Statistical analysis was conducted from April to May 2022.Main Outcomes and MeasuresOutcomes include incidence of VTE, hematoma, and flap pedicle thrombosis events within 30 days of the surgery. Univariate and multivariable regression models were used to evaluate associations between BMI and other patient factors with these outcomes.ResultsAmong the 765 patients included, 262 (34.24%) were female; mean (SD) age was 60.85 (12.64) years; and mean (SD) BMI was 26.36 (6.29). The rates of VTE and hematoma in the cohort were 3.92% (30 patients) and 5.09% (39 patients), respectively. After adjusting for patient factors, BMI was the only factor associated with VTE (OR, 1.07; 95% CI, 1.015-1.129). Obesity (BMI &gt;30) was associated with increased odds of VTE (OR, 2.782; 95% CI, 1.197-6.564). Hematoma was not associated with BMI (OR, 0.988; 95% CI, 0.937-1.041). Caprini score of at least 9 was not associated with VTE (OR, 1.259; 95% CI, 0.428-3.701).Conclusions and RelevanceThis cohort study found that obesity was associated with an increased risk of VTE in patients after microvascular H&amp;N reconstruction and while on standard postoperative chemoprophylaxis regimens. This association may suggest insufficient VTE prophylaxis in this group and a potential indication for weight-based dosing.

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Weight-based enoxaparin dosing for venous thromboembolism prophylaxis in the obese trauma patient

Cited by 78 publications

References 18 publications

Enoxaparin Thromboprophylaxis Dosing and Anti–Factor Xa Levels in Low‐Weight Patients

Enoxaparin Thromboprophylaxis Dosing and Anti–Factor Xa Levels in Low‐Weight Patients

Chemical prophylaxis to prevent venous thromboembolism in morbid obesity: literature review and dosing recommendations

Assessment of BMI and Venous Thromboembolism Rates in Patients on Standard Chemoprophylaxis Regimens After Undergoing Free Tissue Transfer to the Head and Neck

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