Enoxaparin Thromboprophylaxis Dosing and Anti–Factor Xa Levels in Low‐Weight Patients

Yam, Lily; Bahjri, Khaled; Geslani, Van; Cotton, Adrian; Hong, Lisa

doi:10.1002/phar.2295

Cited by 6 publications

(10 citation statements)

References 18 publications

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“…This difference could be explained by the variability of enoxaparin doses used in the retrospective study, with majority of patients received 30 mg once daily. 19 The median dose of enoxaparin administered in the retrospective study (0.6 mg per kg) was similar to that in our study (0.66 mg per kg). Both median doses are lower than that used by Rojas et al who prospectively administered 40 mg enoxaparin to 56 patients weighing < 55 kg, for a calculated median dose of 0.8 mg per kg.…”

Section: Discussionsupporting

confidence: 85%

“…Of note, the definition of low bodyweight was inconsistent among studies assessing enoxaparin prophylaxis, with <55 kg set as a cutoff weight in some studies, irrespective of patient sex. 19,20 A prospective study found a significant increase in bleeding risk among patients receiving enoxaparin for VTE treatment and weighing <55 kg. 27 However, that study assessed a therapeutic dose of enoxaparin (1 mg per kg every 12 hours) for the treatment of an established VTE.…”

Section: Discussionmentioning

confidence: 99%

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Anti-Factor Xa Levels in Low-weight Surgical Patients Receiving Enoxaparin for Venous Thromboembolism Prophylaxis: A Prospective Cohort Study

Hakeam

Duhailib

Alsemari

et al. 2020

Clin Appl Thromb Hemost

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Enoxaparin is indicated for thromboprophylaxis in non-orthopedic surgical patients at a fixed dose of 40 mg daily. According to the US Food and Drug Administration’s enoxaparin prescribing information, this dose exposes low-weight patients (males < 57 kg, females < 45 kg) to a higher risk of bleeding. This study aimed to determine the rate of achieving a prophylactic peak anti-factor Xa (AFXa) level in low-weight surgical patients using enoxaparin 30 mg daily. Low-weight patients admitted for abdominopelvic or noncardiac thoracic surgery from May 2018 to May 2019 were prospectively studied. After receiving daily enoxaparin 30 mg, peak AFXa levels were assessed for achieving a prophylactic level (0.2-0.5 IU/mL). In 121 patients, the proportion of achieving a prophylactic peak AFXa level was 66.1%. More females (84.8%) achieved a prophylactic level compared to males (54.7%, P = .001). All out-of-range peak AFXa levels (33.9%) were sub-prophylactic. The median peak AFXa level was lower in males (0.24 [0.1-0.47] IU/mL) than females (0.31 [0.1-0.5] IU/mL; P < .001). On univariate analysis, female sex and weight were associated with achieving a prophylactic peak AFXa level. On multivariate analysis, only female sex was independently associated with an adequate prophylactic AFXa level (odds ratio 3.17, 95% CI: 1.32-11.94; P = .014). Four venous thromboembolism events (3.3%) were observed in patients with sub-prophylactic peak AFXa levels (9.7%). Two-thirds of low-weight surgical patients achieved a prophylactic peak AFXa level using daily enoxaparin 30 mg. This dose is likely to provide adequate thromboprophylaxis in low-weight females.

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Section: Discussionsupporting

confidence: 85%

Section: Discussionmentioning

confidence: 99%

Anti-Factor Xa Levels in Low-weight Surgical Patients Receiving Enoxaparin for Venous Thromboembolism Prophylaxis: A Prospective Cohort Study

Hakeam

Duhailib

Alsemari

et al. 2020

Clin Appl Thromb Hemost

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“…It has been postulated that standard dosing of prophylactic enoxaparin may represent an over dosage of enoxaparin in low weight patients as current evidence based on anti-factor-Xa data shows that reduced dosing may better achieve target levels of anticoagulation. 8 Of the 171 patients enrolled in our study, a greater percentage of patients were receiving standard dosing of enoxaparin VTE prophylaxis. This potentially could have led to an underpowered reduced dosing group.…”

Section: Discussionmentioning

confidence: 99%

Safety and Effectiveness of Reduced Dose Versus Standard Dose Enoxaparin Venous Thromboembolism Prophylaxis in Underweight Medically Ill Patients

Nemeth

Isherwood

2022

Hosp Pharm

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Background: Enoxaparin is commonly used for venous thromboembolism (VTE) prophylaxis in hospitalized patients. Published literature exists for dose adjustment in higher body weights and renal dysfunction, but sparse literature on optimal dosing of prophylactic enoxaparin in underweight patients exists. Objective: To determine if there is a difference in adverse outcomes or effectiveness if enoxaparin VTE prophylaxis dosing is reduced to 30 mg subcutaneously once daily from standard dosing in underweight medically ill patients. Methods: This study was a retrospective chart review of a total of 171 patients, with 190 individual courses of enoxaparin included. Patients were ≥18 years of age, weighed ≤50 kg, and were given at least 2 days of consecutive therapy. Patients were excluded if they were taking anticoagulation upon admission, had a creatinine clearance <30 mL/min, were admitted to the ICU or a trauma or surgical service, or presented with bleeding or thrombosis. The Padua score and a modified score from the IMPROVE trial were used to evaluate baseline thrombotic risk and bleeding risk, respectively. Bleeding events were classified using the Bleeding Academic Research Consortium criteria. Results: No difference was seen in baseline risk of bleeding or thrombosis when comparing the reduced and standard dosing groups. No differences were observed with rates of bleeding, thrombotic events, mortality, or 30-day readmission. Conclusion: Both reduced and standard dosing strategies appeared effective for VTE prophylaxis, but neither showed superiority in reducing bleeding events. Additional larger studies are needed to evaluate safety and effectiveness of reduced dose of enoxaparin in this patient population.

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“…The hypothesis was supported by prior literature proposing that over-anticoagulation may occur with standard prophylactic LMWH dosing in low body weight patients based on anti-factor Xa level monitoring and that bleeding risk may also increase with advanced age and reduced body weight. 16,17…”

Section: Methodsmentioning

confidence: 99%

Impact of Reduced Enoxaparin Prophylactic Dosing on Bleeding and Thrombotic Risk for Low Body Weight Post-Operative Colorectal Surgery Patients

Cappetto

Dooley

2023

Hosp Pharm

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Introduction: Colorectal surgery (CORS) patients are at the highest risk of any general surgery population for the development of post-operative venous thromboembolism (VTE) and are also at an increased risk for post-operative bleeding, especially with procedures related to early cancer stages. Low molecular weight heparin (LMWH) is recommended for VTE prophylaxis in this surgical population. Current guidelines and primary literature along with institutional protocols support dosage adjustments for obesity and impaired renal function, but literature providing optimal VTE prophylactic LMWH dosing is extremely limited for underweight, surgical patients. Objectives: The aim of this study was to evaluate both bleeding and VTE rates for hospitalized underweight colorectal surgery patients receiving post-operative VTE prophylaxis with standard enoxaparin 40 mg subcutaneously (SQ) every 24 hours versus reduced dose enoxaparin 30 mg SQ every 24 hours. Methods: This trial was a multicenter, retrospective chart review with data collected on post-operative CORS patients over a 10-year period. Patients were included if aged 18 years and older, weighed less than 50 kg, and received at least 1 dose of enoxaparin 40 mg or 30 mg post-operatively. The primary endpoint was a descriptive comparison of post-operative bleeding with use of standard enoxaparin 40 mg SQ every 24 hours compared to reduced dose enoxaparin 30 mg SQ every 24 hours for post-operative VTE prophylaxis. The secondary endpoint was the descriptive comparison of post-operative thrombotic event rates in the same population. Results: The total population investigated included 146 patients. One hundred twenty-nine (88.4%) received standard enoxaparin and 17 (11.6%) received reduced enoxaparin. Overall, 9 bleeding events (7.0%) and 2 major VTE events (1.6%) occurred, all within the standard enoxaparin group. Conclusion: Standard dose enoxaparin for post-operative VTE prophylaxis demonstrated increased bleeding and thrombotic events requiring medical and surgical intervention in comparison to reduced dose enoxaparin for low body weight CORS patients. The results of this study are hypothesis generating and continued research involving more robust systematic reviews are needed to evaluate both safety and efficacy of reduced VTE prophylaxis with LMWH in the underweight, surgical patient population.

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Enoxaparin Thromboprophylaxis Dosing and Anti–Factor Xa Levels in Low‐Weight Patients

Cited by 6 publications

References 18 publications

Anti-Factor Xa Levels in Low-weight Surgical Patients Receiving Enoxaparin for Venous Thromboembolism Prophylaxis: A Prospective Cohort Study

Anti-Factor Xa Levels in Low-weight Surgical Patients Receiving Enoxaparin for Venous Thromboembolism Prophylaxis: A Prospective Cohort Study

Safety and Effectiveness of Reduced Dose Versus Standard Dose Enoxaparin Venous Thromboembolism Prophylaxis in Underweight Medically Ill Patients

Impact of Reduced Enoxaparin Prophylactic Dosing on Bleeding and Thrombotic Risk for Low Body Weight Post-Operative Colorectal Surgery Patients

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