Encouraging the Move Towards Predictive Population Models for the Obese Using Propofol as a Motivating Example

McLeay, Sarah; Morrish, Glynn; Kirkpatrick, Carl M.; Green, Bruce

doi:10.1007/s11095-009-9873-7

Cited by 29 publications

(14 citation statements)

References 31 publications

(38 reference statements)

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“…However, none compared delays with nonobese patients. The use of lean body weight may also represent a promising avenue for dosing medication in the obese patients (12). Our results, however, have not shown a positive correlation with time to achieve threshold aPTT.…”

Section: Obesitycontrasting

confidence: 62%

Delayed efficient anticoagulation with heparin in patients with a weight of 110 kg and more treated for acute coronary syndrome

Joncas

Poirier

Ardilouze

et al. 2013

Obesity

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Objective: The use of a weight-based nomogram is considered as standard care for prescribing appropriate doses of unfractionated heparin (UFH). Because of the need for multiple other medications that may affect bleeding and that clinical data have relied on similar dosing algorithms, maximum initial bolus and infusion rates have been suggested (capped initial dose). Whether these weight-based heparin nomograms properly address therapeutic dosing in obese patients remains questionable. Design and Methods: Thirty patients treated for acute coronary syndrome and weighing !110 kg were retrospectively compared with 90 controls (three groups of 30 patients, weighting 50-69.9, 70-89.9, or 90-109.9 kg), all treated with UFH, July 2008 to April 2009. The primary end point was the time required to obtain a threshold activated partial thromboplastin time (aPTT). Results: Mean time to achieve threshold aPTT was longer for obese patients weighing !110 kg than for controls (31.47 vs. 12.89 hours; P < 0.0001). At 24 hours, 63% of obese patients weighing !110 kg had not reached threshold aPTT vs. 7% of controls (P < 0.0001). However, threshold infusion rate did not differ between weight categories (13.0 vs. 13.1 U/kg/h; P ¼ NS) and approximated the initial infusion rate recommended by nomograms without applying the dose cap (12 U/kg/h). Conclusions: Adequate anticoagulation time doubled in patients weighing !110 kg, suggesting that these patients were not receiving appropriate heparin doses initially to achieve threshold aPTT rapidly. Using initial infusion rate recommended by a nomogram without capping for total body weight is suggested as acceptable in this study. This approach should be further evaluated in a prospective study.

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Section: Obesitycontrasting

confidence: 62%

Delayed efficient anticoagulation with heparin in patients with a weight of 110 kg and more treated for acute coronary syndrome

Joncas

Poirier

Ardilouze

et al. 2013

Obesity

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“…Data are available to provide some guidance on appropriate dosing for common perioperative medications (Table 3). 64,65,[67][68][69][70][71][72][73][74] In Table 4, there is an outline of the calculation methods for the various dosing weights.…”

Section: Intraoperative Carementioning

confidence: 99%

Perioperative management of the severely obese patient: a selective pathophysiological review

Cullen

Ferguson

2012

Can J Anesth/J Can Anesth

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“…The risk for prolonged sedation and CNS depression is less than that of midazolam, which is longer acting and has an active metabolite. Still, there is deeper anesthesia and concern for delayed awakenings by anesthesiologists for overweight patients [43]. ADRs were not observed with propofol in the ICU population in our study.…”

Section: Discussionmentioning

confidence: 51%

A Real‐World, Multicenter Assessment of Drugs Requiring Weight‐Based Calculations in Overweight, Adult Critically Ill Patients

Kane‐Gill

Wytiaz

Thompson

et al. 2013

The Scientific World Journal

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Prescribing appropriate doses of drugs requiring weight-based dosing is challenging in overweight patients due to a lack of data. With 68% of the US population considered overweight and these patients being at an increased risk for hospitalization, clinicians need guidance on dosing weight-based drugs. The purpose of this study was to identify “real-world” dose ranges of high-risk medications administered via continuous infusion requiring weight-based dosing and determine the reasons for dosing changes (ineffectiveness or adverse drug reactions). A prospective, multicenter, observational study was conducted in four intensive care units at three institutions. A total of 857 medication orders representing 11 different high-risk medications in 173 patients were reviewed. It was noted that dosing did not increase in proportion to weight classification. Overall, 14 adverse drug reactions occurred in nine patients with more in overweight patients (9 of 14). A total of 75% of orders were discontinued due to ineffectiveness in groups with higher body mass indexes. Ineffectiveness leads to dosing adjustments resulting in the opportunity for medication errors. Also, the frequent dosing changes further demonstrate our lack of knowledge of appropriate dosing for this population. Given the medications' increased propensity to cause harm, institutions should aggressively monitor these medications in overweight patients.

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Encouraging the Move Towards Predictive Population Models for the Obese Using Propofol as a Motivating Example

Abstract: LBW as a covariate provides a plausible mechanistic explanation for an observed nonlinear increase in drug CL with TBW and may be suitable for developing dosing strategies that are appropriate for use in the obese population.

Cited by 29 publications

References 31 publications

Delayed efficient anticoagulation with heparin in patients with a weight of 110 kg and more treated for acute coronary syndrome

Delayed efficient anticoagulation with heparin in patients with a weight of 110 kg and more treated for acute coronary syndrome

Perioperative management of the severely obese patient: a selective pathophysiological review

A Real‐World, Multicenter Assessment of Drugs Requiring Weight‐Based Calculations in Overweight, Adult Critically Ill Patients

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