Efficacy and Safety of High-Dose Subcutaneous Unfractionated Heparin Prophylaxis for the Prevention of Venous Thromboembolism in Obese Hospitalized Patients

Beall, Jeffrey; Woodruff, Ashley E.; Hempel, Carolyn; Wovkulich, Margaret; Zammit, Kimberly

doi:10.1310/hpj5105-376

Cited by 9 publications

(7 citation statements)

References 15 publications

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“…Because current evidence suggests that the relationship between body mass index (BMI) and incidence of venous thromboembolism (VTE) is linear, the risk for VTE rises as BMI increases . The incidence of VTE was reported to range from 0.1–42% in patients in all BMI subgroups who were either hospitalized (1.43–15%) or seen as outpatients (0.1–42%) . Obesity is suspected to be one of the risk factors for VTE, and the incidence of VTE increases by 6‐fold when BMI exceeds 35 kg/m 2 .…”

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confidence: 99%

“…[1][2][3][4] The incidence of VTE was reported to range from 0.1-42% in patients in all BMI subgroups who were either hospitalized (1.43-15%) or seen as outpatients (0.1-42%). [1][2][3][4][5][6][7][8][9] Obesity is suspected to be one of the risk factors for VTE, and the incidence of VTE increases by 6-fold when BMI exceeds 35 kg/m 2 . 1 Several studies have investigated the relationship between obesity and VTE.…”

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confidence: 99%

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Assessment of the Relationship between Body Mass Index and Incidence of Venous Thromboembolism in Hospitalized Overweight and Obese Patients

Samuel

Gomez

Savarraj³

et al. 2017

Pharmacotherapy

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confidence: 99%

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confidence: 99%

Assessment of the Relationship between Body Mass Index and Incidence of Venous Thromboembolism in Hospitalized Overweight and Obese Patients

Samuel

Gomez

Savarraj³

et al. 2017

Pharmacotherapy

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“…High-dose thromboprophylaxis did not decrease the rate of nosocomial VTE and there was no increased risk of bleeding. 80 Although the previous studies found conflicting evidence, these authors included all hospitalized patients without specifically identifying the critically ill population. Additionally, the event rates for both VTE and bleeding complications showed wide variation across the studies.…”

Section: Subpopulations Of Critically Ill Patients At High-risk Of Thmentioning

confidence: 99%

“…High-Dose Thromboprophylaxis in Obese, Hospitalized Patients [78][79][80][81]. BID, twice daily; BMI, body mass index; CI, confidence interval; HD, high dose; Hgb, hemoglobin; ICU, intensive care unit; OR, odds ratio; PRBC, packed red blood cells; QD, once daily; SD, standard-dose; TID, 3 times daily; UFH, unfractionated heparin; VTE, venous thromboembolism.…”

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confidence: 99%

Venous Thromboembolism Prophylaxis: A Narrative Review With a Focus on the High-Risk Critically Ill Patient

Lewis

Altshuler

Papadopoulos

2018

J Intensive Care Med

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Venous thromboembolism (VTE) is a major health concern associated with significant morbidity and mortality. Critically ill patients are at an increased risk of VTE compared to general medical patients due to unique risk factors: prolonged immobilization, invasive lines and devices, certain medications, and acquired thrombophilia. Furthermore, VTE in the critically ill is associated with increased duration of mechanical ventilation, increased length of intensive care unit and hospital stay, and a trend toward increased mortality. Clinical practice guidelines therefore recommend VTE prophylaxis with either subcutaneous heparin or low-molecular-weight heparin for all critically ill patients without contraindication. Yet, many patients will develop VTE despite appropriate pharmacologic prophylaxis, which has led to interest in risk-stratifying critically ill patients for more aggressive prophylaxis strategies. Recent research identified patients at highest risk of failure of thromboprophylaxis and provided insight into the pathophysiologic mechanisms. Obesity and the receipt of vasopressors are 2 risk factors consistently identified in observational studies; further clinical data support decreased absorption of anticoagulant administered via the subcutaneous route as the likely mechanism behind thromboprophylaxis failure in these patient populations. Several studies have investigated novel thromboprophylaxis strategies to circumvent pharmacokinetic limitations in patients who are obese or on vasopressors: increased fixed-dose, weight-based subcutaneous, or continuous intravenous infusion of a prophylactic dose of anticoagulant has shown promise in limited studies; however, the results have yet to demonstrate superiority compared to current standard-of-care. This review discusses observational studies identifying patients at risk of thromboprophylaxis failure and critiques clinical studies evaluating novel thromboprophylaxis strategies in high-risk, critically ill patients with a focus on their limitations. Future studies are currently being conducted that will provide further guidance into the appropriate use of individualized thromboprophylaxis.

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“…There are data that suggest enoxaparin is superior to UFH, with one meta‐analysis of randomized controlled trials finding a 37% risk reduction compared with UFH in total VTE for medical patients, with a nonsignificant difference in bleeding . Another study found no significant differences between heparin 7500 units SC every 8 hours compared with 5000 units SC every 8 hours, suggesting that high‐dose UFH may not benefit obese patients . However, that study had limitations, such as differences in baseline factors that increased bleeding and VTE risk in the high‐dose group.…”

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confidence: 99%

High-Dose Venous Thromboembolism Prophylaxis for Obese Patients

Turco

Samuel²,

Choi³

2016

Pharmacotherapy

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I would like to thank the authors of the recent article "Safety and Efficacy of High-dose Unfractionated Heparin for Prevention of Venous Thromboembolism in Overweight and Obese Patients" that has contributed more to the body of literature in venous thromboembolism (VTE) prophylaxis for patients with obesity. 1 This study provided evidence against the use of high-dose unfractionated heparin (UFH) thromboprophylaxis for obese patients. These results differ from those of a previous study that found a lower incidence of VTE for patients on high-dose UFH. 2 This conflicting evidence may leave clinicians unsure of how to provide appropriate thromboprophylaxis for obese patients. The conflicting findings of these two studies could be related to differences in study designs and analysis.One of these differences is that patients were compared by body mass index (BMI) every 5 kg/m 2 by the more recent study, whereas the other one compared BMI lower than 40 kg/m 2 to BMI higher than 40 kg/m 2 . Because the latter authors only found a lower incidence of VTE on high-dose thromboprophylaxis for those with a BMI higher than 40 kg/m 2 , would the authors of the more recent study have found a benefit if they had compared all those with a BMI higher than 40 kg/m 2 with all those with a BMI lower than 40 kg/m 2 ?The older trial included enoxaparin 40 mg subcutaneously (SC) twice/day as a high-dose option.There are data that suggest enoxaparin is superior to UFH, with one meta-analysis of randomized controlled trials finding a 37% risk reduction compared with UFH in total VTE for medical patients, with a nonsignificant difference in bleeding. 3 Another study found no significant differences between heparin 7500 units SC every 8 hours compared with 5000 units SC every 8 hours, suggesting that high-dose UFH may not benefit obese patients. 4 However, that study had limitations, such as differences in baseline factors that increased bleeding and VTE risk in the highdose group. Therefore, the inclusion of enoxaparin in the older study as compared with only UFH by the more recent one may have driven the differences in observed outcomes. By including high-dose enoxaparin as a high-dose thromboprophylaxis option and by analyzing the effect of enoxaparin separately from UFH, a benefit may have been found in the more recent study.Because studies like these help increase our understanding in this area, they also lead to further questions. More specific evidence is needed to guide the approach to VTE prophylaxis properly in obese patients. Future studies to decrease the incidence of VTE while minimizing the risk of bleeding should examine the use of high-dose VTE prophylaxis with enoxaparin 40 mg SC twice/day for those with a BMI higher than 40 kg/m 2 . References 1. Joy M, Tharp E, Hartman H, Schepcoff S, et al. Safety and efficacy of high-dose unfractionated heparin for prevention of venous thromboembolism in overweight and obese patients. Pharmacotherapy 2016;36(7):740-8.

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Efficacy and Safety of High-Dose Subcutaneous Unfractionated Heparin Prophylaxis for the Prevention of Venous Thromboembolism in Obese Hospitalized Patients

Cited by 9 publications

References 15 publications

Assessment of the Relationship between Body Mass Index and Incidence of Venous Thromboembolism in Hospitalized Overweight and Obese Patients

Assessment of the Relationship between Body Mass Index and Incidence of Venous Thromboembolism in Hospitalized Overweight and Obese Patients

Venous Thromboembolism Prophylaxis: A Narrative Review With a Focus on the High-Risk Critically Ill Patient

High-Dose Venous Thromboembolism Prophylaxis for Obese Patients

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