Efficacy and safety of high-dose thromboprophylaxis in morbidly obese inpatients

Wang, Tzu‐Fei; Milligan, Paul E.; Wong, Catherine; Deal, Eli N.; Thoelke, Mark; Gage, Brian F.

doi:10.1160/th13-01-0042

Cited by 130 publications

(131 citation statements)

References 51 publications

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“…23 When subcutaneously administered unfractionated heparin was used for thromboprophylaxis, a dosage of 7500 units 3 times per day was found to be more effective than standard dosing (5000 units 2 or 3 times per day) in preventing VTE and did not increase bleeding in patients with BMI $40 kg/m 2 . 24 …”

Section: Heparinmentioning

confidence: 99%

Thrombosis in the setting of obesity or inflammatory bowel disease

Lentz

2016

Blood

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Obesity and inflammatory bowel disease (IBD) are systemic inflammatory disorders that predispose to arterial and venous thrombosis through similar prothrombotic mechanisms. Obesity and IBD are chronic risk factors that lead to a persistently elevated risk of thrombosis, although the thrombotic risk with IBD appears to wax and wane with disease severity. Because of the lack of high-quality evidence to guide management decisions, approaches to the prevention and treatment of thrombosis in patients with obesity or IBD are based on extrapolation from general guidelines for antithrombotic therapy. Obesity alters the pharmacokinetics of some anticoagulant drugs, and IBD patients present the added management challenge of having a high risk of gastrointestinal bleeding while taking anticoagulants. An extended duration of anticoagulant therapy is often recommended for obese or IBD patients with unprovoked venous thromboembolism unless there is a high risk of bleeding, although more data and better biomarkers are needed to determine whether anticoagulation can be safely stopped in a subset of IBD patients during remission of active disease. Most patients with obesity or IBD require thromboprophylaxis in conjunction with hospitalization or surgery, with adjustment of anticoagulant dosing in patients with severe obesity.

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Section: Heparinmentioning

confidence: 99%

Thrombosis in the setting of obesity or inflammatory bowel disease

Lentz

2016

Blood

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“…The trial that is likely most useful to guide specific dosing recommendations in obese populations comes from a recent retrospective study of 3,928 morbidly obese inpatients [33]. This study included a total of 9241 patients with a body weight [100 kg; 6677 who received standard dosing of DVT prophylaxis (enoxaparin 40 mg daily or UFH 5000 units two to three times daily) and 2432 who received higher prophylactic doses (enoxaparin 40 mg twice daily or UFH 7500 units three times daily) [33].…”

Section: Alternate Dosing Strategies In Morbid Obesitymentioning

confidence: 99%

“…This study included a total of 9241 patients with a body weight [100 kg; 6677 who received standard dosing of DVT prophylaxis (enoxaparin 40 mg daily or UFH 5000 units two to three times daily) and 2432 who received higher prophylactic doses (enoxaparin 40 mg twice daily or UFH 7500 units three times daily) [33]. The study stratified patients further into two groups, those who had a BMI \ 40 kg/m 2 (5313 patients) and those who had a BMI C 40 mg/m 2 (3928 patients) [33].…”

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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“…The UFH dose recommended in the review was 7,500 IU SC (2 or 3 times a day), based on a retrospective study with a large number of patients. 20 Still with relation to the same review, the recommended dose of fondaparinux was 2.5 mg SC per day; but a study published by Steele et al 16 recommended a dose of 5 mg SC per day.…”

mentioning

confidence: 99%

“…Apparently, therefore, either enoxaparin at a dosage of 40 mg twice a day or fondaparinux (5mg/day) can be recommended for patients with BMI > 40 kg/m . [18][19][20] According to the same review mentioned above, 17 the 0.5 mg/kg enoxaparin regimen is associated with a greater degree of inconvenience, since it has been validated much less and is prone to dosage errors, and because the presentation of enoxaparin is in ready-to-use syringes in fixed doses, making it difficult to divide into smaller doses. The UFH dose recommended in the review was 7,500 IU SC (2 or 3 times a day), based on a retrospective…”

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confidence: 99%

Profilaxia do tromboembolismo venoso em cirurgia bariátrica

Yoshida

2017

J. vasc. bras.

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Bariatric surgery was defined as high risk for development of venous thromboembolism (VTE) in the 2012 ninth edition of the American College of Chest Physicians' (ACCP) Consensus, along with surgery for gynecological cancer, pneumonectomy, craniotomy and traumas involving the brain or spinal cord, or other major traumas.1 Without prophylaxis, the incidence of deep venous thrombosis (DVT) in this risk category ranges from 40 to 80% distally in the leg and from 10 to 20% proximally in the thigh, with a 0.2-5.0% incidence of fatal pulmonary embolism (PE).2 Data for bariatric surgery patients corroborate these findings, with DVT frequencies of 0.2-2.4% and PE rates of 1-2%, 3-6 the latter being responsible for 30-50% of mortality related to the operation. [7][8][9][10] In view of this, prophylaxis for VTE is mandatory.A meta-analysis conducted by Becattini et al. 11 found that the regimens most often used for bariatric surgery patients were as follows:1. Unfractionated heparin (UFH) -at a dosage of 5,000 international units (IU) subcutaneously (SC) 3 times a day for 15 days.2. Low molecular weight heparin (LMWH) -enoxaparin at a dosage of 30 mg SC twice a day or 40 mg twice a day for 15 days.Adjusting doses for Anti-Xa provoked an increase in the frequency of bleeding without reducing VTE.11 Irrespectively, pharmacological prophylaxis must always be managed on a case-by-case basis, considering the risk of bleeding in each case (active peptic ulcer, uncontrolled systemic arterial hypertension, coagulopathy, thrombocytopenia, renal failure, etc.). 12Enoxaparin can be administered at a dosage of 60 mg twice a day for 14 days.12 A study that compared this with a dosage of 40 mg twice a day for 14 days found that the risk of bleeding was similar in both groups. This study did not assess VTE frequency during the postoperative period.Stroh et al. 13 analyzed registry data compiled in Germany on 31,668 surgeries (13,772 Roux-en-Y-gastric bypasses, 11,840 sleeve gastrectomies and 3,999 gastric bandings) reporting DVT in 0.07% of cases and PE in 0.10% and concluding that LMWH was preferable to unfractionated heparins. These data were recently corroborated by an analysis conducted by different authors.14 In these data, around 94.4% of procedures were Roux-en-Y open surgeries and 5.6% were laparoscopies.Some authors prefer to combine HNF with mechanical prophylaxis, such as early mobilization, intermittent pneumatic compression (IPC), and graduated elastic compression stockings (GECS). 12,15In a randomized study comparing fondaparinux (5 mg/day) with enoxaparin (40 mg twice a day), 16 the results for complications (VTE) during the postoperative period were similar in two groups with body mass index (BMI) > 40 kg/m 2 . However, fondaparinux was associated with better control of anti-Xa levels. Apparently, therefore, either enoxaparin at a dosage of 40 mg twice a day or fondaparinux (5mg/day) can be recommended for patients with BMI > 40 kg/m . [18][19][20] According to the same review mentioned above, 17 the 0.5 mg/kg eno...

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Efficacy and safety of high-dose thromboprophylaxis in morbidly obese inpatients

Cited by 130 publications

References 51 publications

Thrombosis in the setting of obesity or inflammatory bowel disease

Thrombosis in the setting of obesity or inflammatory bowel disease

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

Profilaxia do tromboembolismo venoso em cirurgia bariátrica

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