Julie Farrar, PharmD, BCCCP (she/her/hers)
Assistant Professor
University of Tennessee College of Pharmacy
Memphis, Tennessee
Disclosure information not submitted.
Carolyn Philpott, PharmD, BCCCP
Clinical Pharmacy Specialist
University of Cincinnati Medical Center, United States
Disclosure information not submitted.
Chris Droege, PharmD, BCCCP, FCCM
UC Health/University of Cincinnati Medical Center
Cincinnati
Disclosure information not submitted.
Neil Ernst, PharmD
Clinical Pharmacy Specialist
University of Cincinnati Medical Center, United States
Disclosure information not submitted.
Eric Mueller, PharmD, FCCP, FCCM
Clinical Pharmacy Specialist
University of Cincinnati Medical Center
Cincinnati, Ohio, United States
Disclosure information not submitted.
Stephanie Katampe
Pharmacy Student
University of Cincinnati Medical Center, United States
Disclosure information not submitted.
Erin O'Toole
Pharmacy Student
University of Cincinnati Medical Center, United States
Disclosure information not submitted.
Claire Roell
Pharmacy Student
University of Cincinnati Medical Center, United States
Disclosure information not submitted.
Amy Makley, MD, FACS
Associate Professor of Surgery
University of Cincinnati College of Medicine, United States
Disclosure information not submitted.
Henry Sagi, MD, FACS
Professor of Orthopaedic Trauma Surgery
University of Cincinnati College of Medicine, United States
Disclosure information not submitted.
Molly Droege, PharmD
Clinical Pharmacy Specialist
UC Health/University of Cincinnati Medical Center
Cincinnati, Ohio, United States
Disclosure information not submitted.
Title: Quasi-experimental Evaluation of a Weight-tiered, anti-Xa Enoxaparin Prophylaxis Protocol in Trauma
Introduction: Low molecular weight heparin (LMWH) is recommended for the prevention of venous thromboembolism (VTE) in trauma patients. Consensus is lacking for ideal dosing and monitoring strategies. This study evaluated a weight-tiered chemoprophylaxis protocol that included anti-Xa-based escalation of enoxaparin dose.
Methods: This was a single center, quasi-experimental study of adult patients admitted to the trauma service at an urban, academic, level-I trauma center during two protocolized epochs: August 2018 through July 2019 (PRE) and August 2019 through July 2020 (POST). PRE patients were stratified based on Greenfield Risk Assessment Profile (RAP): RAP < 5 received unfractionated heparin (UFH) 5000 units every 8 hours; RAP ≥5 received enoxaparin 30 mg (or 40 mg if weight ≥125 kg) every 12 hours with a one-time 10 mg dose escalation for steady state trough anti-Xa < 0.1 IU/mL. Irrespective of RAP, POST patients received enoxaparin per a weight-tiered initial dose (30 mg if ≤90 kg; 40 mg if 90-119 kg; 50 mg if 120-149kg; 60 mg if ≥150kg) every 12 hours with 10 mg titration targeting a goal trough anti-Xa 0.1-0.2 IU/mL. UFH could be used in either epoch for renal dysfunction (creatinine clearance < 30 mL/min). The primary outcome was VTE incidence.
Results: A total of 1,497 patients were included: 677 PRE and 820 POST. POST patients more often received enoxaparin instead of UFH as initial chemoprophylaxis (205 [36.9%] v 684 [83.6%]; p< 0.01). VTE incidence was similar between groups (23 [3.4%] v 34 [4.2%]; p=0.54) including subgroups with RAP ≥5 and enoxaparin as the initial agent. POST patients trended towards higher rates of goal anti-Xa attainment on initial enoxaparin dose (100 [33.9%] v 233 [40.2%]; p=0.083). A higher proportion of POST patients achieved goal anti-Xa overall during enoxaparin therapy (131 [44.4%] v 364 [62.8%]; p < 0.001). Transfusion requirements were similar between groups.
Conclusion: Initial, weight-tiered enoxaparin dosing with anti-Xa adjustment achieved higher rates of goal anti-Xa attainment but did not influence VTE or bleeding endpoints. Amid contemporary rates of VTE, future studies require larger sample sizes and multicenter designs to have adequate power to determine the optimal enoxaparin dosing strategy.