.jpg "Richard Mioni, BCCCP, BCPS, PharmD photo")
Richard Mioni, BCCCP, BCPS, PharmD
Critical Care Clinical Pharmacy Specialist
Franciscan Health Olympia Fields
Olympia Fields, Illinois
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Meagan Latham, BCCCP, BCPS, PharmD
Clinical Pharmacy Specialist - Medical ICU
Franciscan Health Olympia Fields
Olympia Fields, Illinois
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Edward Wright
Critical Care Fellow
Franciscan Health Olympia Fields, United States
Disclosure information not submitted.
Ravi Sundaram, DO
Intensivist/ Pulmonologist
Franciscan Saint James Health, United States
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Shil Punatar
Internal Medicine Resident
Franciscan Olympia Fields, United States
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Alessandra Carrillo
Internal Medicine Resident
Franciscan Olympia Fields, United States
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Title: Optimizing Intermediate Prophylactic Anticoagulation Dosing With Anti-Xa Monitoring in COVID-19
Introduction/Hypothesis: COVID-19 is associated with a prothrombotic state and increased incidence of thromboembolic disease. Studies comparing intermediate-dose vs. standard-dose prophylaxis have mixed results, ranging from worse outcomes to better outcomes. Consequently, practice variation continues among ICUs. The venous thromboembolism (VTE) rate in adults with COVID-19 vary. In a recent meta-analysis by Hasan et al, a rate of 31% was reported for critically ill adults receiving prophylactic or therapeutic anticoagulation. However, anticoagulants increase bleeding risk and warrant additional monitoring. Taquard et al reported 7.2% bleeding rate with high dose-prophylactic dosing in critically ill COVID-19 cases. The objective of the study was to determine if initial intermediate prophylactic dosing, with anti-Xa monitoring and dose optimization, decreased the risk of VTE in critically ill adults with COVID-19.
Methods: This was a retrospective, observational study in a 31-bed mixed ICU. Critically ill adults, with a creatine clearance of ≥ 30 mL/min, and a positive COVID-19 test from 5/21/2020 to 5/7/2021, were started on enoxaparin 40 mg subcutaneously every 12 hours. Peak anti-Xa levels were drawn at steady state and the goal level was 0.2-0.5 IU/mL. Doses were adjusted by 20% if anti-xa levels were not at goal. Once at goal, follow-up anti-Xa levels were drawn every 1-2 weeks. Data endpoints assessed included anti-Xa level, peak D-dimer, incidence of pulmonary emboli (PE), deep vein thrombosis (DVT), bleeding requiring transfusion, ICU length of stay (LOS), hospital LOS, and mortality. Data below are presented as median (IQR).
Results: One hundred seven adults were included in the study with 205 anti-Xa levels at steady state. Peak D-dimer was 1955 ng/mL (1134, 76983), 8 patients (7.5%) had a DVT, and no PEs were detected. Six patients (5.5%) had bleeding that required a transfusion. The ICU LOS was 9 days (5, 40.5). Of the 205 anti-Xa levels obtained, 67 (33%) prompted adjustments to optimize the enoxaparin dose.
Conclusions: In conclusion, intermediate-dose prophylaxis, with anti-Xa level monitoring and dose optimization, demonstrated a lower VTE rate and similar bleeding rate compared to literature reported for the standard dosing approach in the critically ill adults with COVID-19.