Capped antithrombin III dosing is cost effective in the management of asparaginase‐associated thrombosis

Abstract

Asparaginase therapy induces a transient antithrombin III (ATIII) deficiency, which contributes to the risk of asparaginase‐induced thrombosis. At Cincinnati Children's Hospital Medical Center, management of asparaginase‐induced thrombosis includes ATIII supplementation during therapeutic anticoagulation with enoxaparin. Due to the expense associated with ATIII, a capped dosing approach for ATIII was evaluated in this population. Peak ATIII levels were obtained following capped doses to evaluate response. In this pilot evaluation, 11 patients received a total of 138 capped doses for a total cost savings of $803 782. This pilot evaluation represents the first reported analysis of capped ATIII dosing in oncology patients.

Impact of exogenous antithrombin on low molecular weight heparin anti‐Xa activity assays in a pediatric and young adult leukemia and lymphoma cohort with variable antithrombin levels

“…A recent single‐center study of exogenous AT supplementation demonstrated reduced incidence of recurrent VTE, 4 and while efficacy is unclear, AT use in pediatrics is rising 13 . There is lack of uniformity about threshold for AT replacement, and <70% was adapted at our institution based on published cut‐off values for AT supplementation in anticoagulated ALL/L patients 4,12 …”

“…LMWH effect on coagulation factor Xa depends upon AT. Although the safety and efficacy of thromboprophylaxis with AT supplementation during induction chemotherapy continues to be evaluated, 7‐11 our institution has a protocol for supplementation of AT if <70% in anticoagulated ALL and lymphoma (ALL/L) patients with thrombosis who are receiving L‐asparaginase 4,12,13 . How much variable AT activity impacts the gold‐standard anti‐Xa assay for LMWH monitoring is unclear.…”

Antithrombin Therapy: Current State and Future Outlook

“…The cost of AT therapy has been described as a barrier to its use, 145 but the patient benefits associated with AT therapy can offset upfront costs. 99,[145][146][147] The acquisition cost of ATc varies between and within institutions and according to other location-and time-sensitive economic factors.…”

“…The cost of AT therapy has been described as a barrier to its use, 145 but the patient benefits associated with AT therapy can offset upfront costs. 99,[145][146][147] The acquisition cost of ATc varies between and within institutions and according to other location-and time-sensitive economic factors. 146 A 2018 costeffectiveness study from the Johns Hopkins Hospital estimated the acquisition cost of a 500U vial of ATc (Thrombate III) to be US$2330 or $4.66 per unit.…”

“…Several cost-effectiveness strategies have been identified for ATc use, including rounding to full-vial sizes, weight-based dosing with restriction criteria, capped dosing protocols, and reductions in use of other blood products. 14,[145][146][147]151 One institution that rounded doses to a full-vial size if within 10% of the originally prescribed dose saw a median cost savings of US$1692 per dose and reduced waste of a median of 363 units per dose. 14 Other centers have adopted a similar full-vial use strategy to minimize wasted ATc, which resulted in savings from avoiding unused ATc product and reductions in the needed dose of other blood products.…”