Anti-Xa guided enoxaparin dose adjustment improves pharmacologic deep venous thrombosis prophylaxis in burn patients

Cronin, Brett; Godat, Laura N; Berndtson, Allison E.; Pham, Arielle; Kolan, Shobha; Box, Kevin; Lee, Jeanne G.; Costantini, Todd W.

doi:10.1016/j.burns.2019.02.011

Cited by 26 publications

(19 citation statements)

References 34 publications

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“…When choosing the initial dose, 40 mg of enoxaparin twice daily should be considered the standard for most trauma patients, as 30 mg twice daily frequently results in inadequate pharmacologic prophylaxis. 47 – 55 Therefore, patients 18 to 65 years with weight of more than 50 kg and a creatinine clearance of more than 60 mg/dL should be started on 40 mg of enoxaparin twice daily, as this dose is safe and reduces the VTE rate. 47 – 55 Patients who are older than 65 years, weigh less than 50 kg, or who have a creatinine clearance of 30 to 60 mg/dL should continue to receive initial dosing at 30 mg of enoxaparin twice daily.…”

Section: Algorithmmentioning

confidence: 99%

“… 47 – 49 , 75 Although some debate exists on the appropriate target for anti-Xa levels, consensus suggests targeting 0.2 to 0.4 IU/mL for peak levels or 0.1 to 0.2 IU/mL for trough levels. 47 – 50 , 55 , 75 , 76 Anti-Xa monitoring should also be considered for those patients who receive weight-based enoxaparin. 50 , 53 , 76 …”

Section: Algorithmmentioning

confidence: 99%

See 1 more Smart Citation

Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm

Ley

Brown

Moore³

et al. 2020

J Trauma Acute Care Surg

157

260

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Section: Algorithmmentioning

confidence: 99%

Section: Algorithmmentioning

confidence: 99%

Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm

Ley

Brown

Moore³

et al. 2020

J Trauma Acute Care Surg

157

260

View full text Add to dashboard Cite

“…There have been many studies examining the relationship of enoxaparin dose and anti-Xa level, although notably, many of these studies are underpowered or retrospective. [10][11][12][13][14][15] Studies have shown that fixed dosing of enoxaparin (either enoxaparin 40 mg daily or the more recent trauma standard of enoxaparin 30 mg twice daily) is often ineffective in achieving an adequate anti-Xa level, and that patients with subtherapeutic anti-Xa levels have more VTE events. [10][11][12][13][14][15] Research in the trauma surgery population generally supports the notion that VTE rates are reduced when anti-Xa levels are in range.…”

mentioning

confidence: 99%

Enoxaparin titrated by anti-Xa levels reduces venous thromboembolism in trauma patients

Gates

Lollar

Collier

et al. 2021

J Trauma Acute Care Surg

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BACKGROUND:Trauma is a major risk factor for the development of a venous thromboembolism (VTE). After observing higher than expected VTE rates within our center's Trauma Quality Improvement Program data, we instituted a change in our VTE prophylaxis protocol, moving to enoxaparin dosing titrated by anti-Xa levels. We hypothesized that this intervention would lower our symptomatic VTE rates. METHODS:Adult trauma patients at a single institution meeting National Trauma Data Standard criteria from April 2015 to September 2019 were examined with regards to VTE chemoprophylaxis regimen and VTE incidence. Two groups of patients were identified based on VTE protocol-those who received enoxaparin 30 mg twice daily without routine anti-Xa levels ("pre") versus those who received enoxaparin 40 mg twice daily with dose titrated by serial anti-Xa levels ("post"). Univariate and multivariate analyses were performed to define statistically significant differences in VTE incidence between the two cohorts. RESULTS:There were 1698 patients within the "pre" group and 1406 patients within the "post" group. The two groups were essentially the same in terms of demographics and risk factors for bleeding or thrombosis. There was a statistically significant reduction in VTE rate ( p = 0.01) and deep vein thrombosis rate ( p = 0.01) but no significant reduction in pulmonary embolism rate ( p = 0.21) after implementation of the anti-Xa titration protocol. Risk-adjusted Trauma Quality Improvement Program data showed an improvement in rate of symptomatic pulmonary embolism from fifth decile to first decile. CONCLUSION:A protocol titrating prophylactic enoxaparin dose based on anti-Xa levels reduced VTE rates. Implementation of this type of protocol requires diligence from the physician and pharmacist team. Further research will investigate the impact of protocol compliance and time to appropriate anti-Xa level on incidence of VTE.

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“…10 The VTE rate was decreased when enoxaparin dosing was adjusted compared to standard enoxaparin 30 mg, but the manner in which it was adjusted varied and suggests that weight-based dosing of enoxaparin at .5 mg/kg/dose might be successful. [4][5][6][7]11,12 Comparisons among these studies are challenging as some utilized anti-Xa peak levels as opposed to trough, and additionally some studies only included ICU patients. 11 Rather than determining the adequate enoxaparin dose by anti-Xa level or VTE rate, we reviewed predictors of low-dose enoxaparin in trauma patients to demonstrate that only CrCl was associated with lower enoxaparin dose.…”

Section: Discussionmentioning

confidence: 99%

“…2 Higher dosing of enoxaparin by anti-factor Xa level may be associated with a decreased rate of VTE without increasing the bleeding risk. [3][4][5][6][7] As many patients require several days to reach the appropriate dose for VTE prophylaxis, starting selected patients at an initial enoxaparin dose of 40 mg twice daily may be preferable to 30 mg twice daily. In one study, 39.4% of patients failed to reach a goal prophylactic dose despite attempts to titrate the enoxaparin dose.…”

Section: Introductionmentioning

confidence: 99%

Which Trauma Patients Require Lower Enoxaparin Dosing for Venous Thromboembolism Prophylaxis?

Veatch

Hashim

Dhillon

et al. 2020

The American Surgeon™

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Trauma patients have a high risk for venous thromboembolism (VTE) such that an increased enoxaparin dose is necessary to reduce related complications. Given that most trauma patients require an enoxaparin dose of at least 40 mg every 12 hours for VTE prophylaxis, we sought to identify which patients require enoxaparin 30 mg every 12 hours and hypothesized that both weight and low creatinine clearance (CrCl) would more likely determine enoxaparin dosing than age, body mass index (BMI), or body surface area (BSA). Single institution data were collected on trauma patients between August 2014 and February 2018 to compare trauma patients who required enoxaparin 30 mg to those who required ≥40 mg every 12 hours. Of the 245 patients included, 86 (35.1%) required enoxaparin at 30 mg to achieve the goal anti-factor Xa trough level. Factors associated with low dose enoxaparin were older age (59.6 vs. 46.2 years, P ≤ .01) and lower CrCl (81.5 mL/min vs. 93.7 mL/min, P ≤ .01). Weight, BSA, and BMI did not alter the dose of enoxaparin. A regression model determined that only CrCl predicted the need for low dose enoxaparin (adjusted odds ratio .982, 95% CI: .975-.990, P < .01). Although an initial dose of enoxaparin 40 mg is appropriate for most trauma patients, patients with low CrCl should receive 30 mg. Increased age and low weight were not associated with the need for a lower enoxaparin dose.

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Anti-Xa guided enoxaparin dose adjustment improves pharmacologic deep venous thrombosis prophylaxis in burn patients

Cited by 26 publications

References 34 publications

Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm

Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm

Enoxaparin titrated by anti-Xa levels reduces venous thromboembolism in trauma patients

Which Trauma Patients Require Lower Enoxaparin Dosing for Venous Thromboembolism Prophylaxis?

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