The Use of Low Molecular Weight Heparin for Venous Thromboembolism Prophylaxis in Medical Patients: How Much Are We Adherent to the Guidelines?

DOI: 10.4236/ojim.2015.54012   PDF   HTML   XML   3,998 Downloads   5,080 Views   Citations

Abstract

Background: Venous thromboembolism (VTE) is a common complication seen during or after hospitalization that manifests as deep venous thrombosis (DVT) and/or pulmonary embolism (PE). PE is considered the commonest preventable cause of death during and/or after hospitalization. Thus, pharmacological and mechanical methods are used to prevent VTE in hospitalized patients. Despite the availability of guidelines for VTE prophylaxis, it is crucial to assess the adherence and adaptation of the institution to these guidelines. Purpose: This study aimed to investigate adherence to the American College of Chest Physicians (ACCP) 2012 VTE prophylaxis guidelines in hospitalized medical patients in a tertiary care hospital in the United Arab Emirates. Methods: An observational prospective design was utilized in this study. To achieve the purpose, primary and secondary end points were identified to be the core of the investigation. The primary end points were: the incidence of bleeding, VTE, and cardiovascular events. While the secondary end points were: dose and indication validity for prophylaxis, VTE and bleeding risk assessments, adverse drug events (ADE) other than bleeding, appropriate monitoring when on low molecular weight heparin (LMWH) and the presence of contraindication at the time of prescribing LMWH. Results: 16 patients (20%) out of the total 80 met one or more of the primary end points. The vast majority of patients (81.25%) developed bleeding, while VTE was seen in one case only during hospitalization. 11 patients (13.75%) received LMWH while a contraindication was present. 15 patients (18.75%) who were prescribed LMWH had an International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score of ≥7. However, 5 out of 13 patients (38.46%) who developed bleeding had a bleeding score of ≥7, and the relationship between bleeding score of ≥7 and the development of bleeding was statistically significant (p = 0.047). When investigating the doses that were utilized, 40% were prescribed an inappropriate dose. Conclusion: Various factors played a role in the inappropriateness of VTE prophylaxis such as; poor adherence to VTE guidelines, inappropriate dosing and monitoring, and not evaluating the bleeding risk. Hence, to be able to achieve effective VTE prophylaxis, these factors need to be addressed through adherence to and adaptation of the ACCP 2012 VTE prophylaxis guidelines.

Share and Cite:

AlHajri, L. and Gebran, N. (2015) The Use of Low Molecular Weight Heparin for Venous Thromboembolism Prophylaxis in Medical Patients: How Much Are We Adherent to the Guidelines?. Open Journal of Internal Medicine, 5, 81-91. doi: 10.4236/ojim.2015.54012.

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1] Thompson, B. and Hales, C. (2014) Overview of Acute Pulmonary Embolism.
http://www.uptodate.com/contents/overview-of-acute-pulmonary-embolism?source=search_result&
search=PE%2Fdvt&selectedTitle=4%7E150
[2] Anderson Jr., F.A., Zayaruzny, M., Heit, J.A., Fidan, D. and Cohen, A.T. (2007) Estimated Annual
Numbers of US Acute-Care Hospital Patients at Risk for Venous Thromboembolism. American Journal
of Hematology, 82, 777-782. http://dx.doi.org/10.1002/ajh.20983
[3] Dismuke, S. and Wagner, E. (1986) Pulmonary Embolism as a Cause of Death.
The Changing Mortality in Hospitalized Patients. JAMA, 255, 2039.
http://dx.doi.org/10.1001/jama.1986.03370150081032
[4] Horlander, K.T., Manninom, M. and Leeper, KV. (2003) Pulmonary Embolism Mortality in the United States, 1979- 1998: An Analysis Using Multiple-Cause Mortality Data. Archives of Internal Medicine, 163, 1711.
http://dx.doi.org/10.1001/archinte.163.14.1711
[5] Chisholm-Burns, M., Wells, B., Schwinghammer, T., Malone, P., Kolesar, J., Rotschafer, J. and Dipiro,
J. (2008) Pharmacotherapy: Principles & Practice. The McGraw-Hill Companies, Inc., New York.
[6] Khan, S., Dunn, A., Klein, R., et al. (2012) Prevention of VTE in Nonsurgical Patients: Antithrombotic
Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST, 141, e195S-e226S.
http://dx.doi.org/10.1378/chest.11-2296
[7] Scaglione, L., Piobbici, M., Pagano, E., Ballini, L., Tamponi, G and Ciccone, G. (2005) Implementing
Guidelines for Venous Thromboembolism Prophylaxis in a Large Italian Teaching Hospital: Lights and
Shadows. Haematologica, 90, 678-684.
[8] Bateman, A., Sheaff, R., Child, S., et al. (2013) The Implementation of NICE Guidelines on Venous
Thromboembolism Risk Assessment and Prophylaxis; A Before-After Observational Study to Assess the
Impact on Patient Safety Across Four Hospitals in England. BioMed Central, 13, 1-7.
[9] CPOE: Cerner.com. http://www.cerner.com/solutions/Hospitals_and_Health_Systems/CPOE/
[10] Decousus, H., Tapson, V., Bergmann, J., et al. (2011). Factors at Admission Associated With Bleeding
Risk in Medical Patients; Findings from the IMROVE Investigators. CHEST, 139, 69-79.
http://dx.doi.org/10.1378/chest.09-3081
[11] Leizorovicz, A., Cohen, A.T., Turpie, A.G., Olsson, C.G., Vaitkus, P.T. and Goldhaber, S.Z. (2004)
Randomized, Placebo-Controlled Trial of Dalteparin for the Prevention of Venous Thromboembolism in
Acutely Ill Medical Patients. Circulation, 110, 874-879.
http://dx.doi.org/10.1161/01.CIR.0000138928.83266.24
[12] Samama, M., Cohen, T, Darmon, J., et al. (1999) A Comparison of Enoxaparin with Placebo for the
Prevention of Venous Thromboembolism in Acutely Ill Medical Patients. Prophylaxis in Medical Patients
with Enoxaparin Study Group. New England Journal of Medicine, 341, 793-800.
http://dx.doi.org/10.1056/nejm199909093411103
[13] Jetha, L. (2007) A Drug Usage Review of Therapeutic Doses of Enoxaparin at Barnet and Chase Farm
Hospitals. London Pharmacy Education and Training Pzifer Project Awards.
http://www.londonpharmacy.nhs.uk/educationandtraining/prereg/pfizerProjectAwards2007/leila%20
jetha%20Barnet%20and%20Chase%20Farm%20Hospital%20Trust.pdf
[14] Pugh, M., Fincke, B., Bierman, A., et al. (2005) Potentially Inappropriate Prescribing in Elderly Veterans:
Are We Using the Wrong Drug, Wrong Dose, or Wrong Duration? Journal of the American Geriatrics Society, 53, 1282-1289.
http://dx.doi.org/10.1111/j.1532-5415.2005.53402.x
[15] Yu, H., Dylan, M., Lin, J. and Dubois, R. (2007) Hospitals’ Compliance with Prophylaxis Guidelines for
Venous Thromboembolism. American Journal of Health-System Pharmacy, 64, 69-76.
http://dx.doi.org/10.2146/ajhp060115
[16] Selby, R. and Geerts, W. (2009) Prevention of Venous Thromboembolism: Consensus, Controversies, and Challenges. American Society of Hematology, 2009, 286-292.
http://dx.doi.org/10.1182/asheducation-2009.1.286
[17] Coutre, S. (2014) Clinical Presentation and Diagnosis of Heparin-Induced Thrombocytopenia.
http://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-heparin-inducedthrombocytopenia?source=search_result&search=HITT&selectedTitle=1%7E150
[18] Lo, G.K., Juhl, D., Warkentin, T., Sigouin, C., Eicheler, P. and Greinacher, A. (2004) Evaluation of Pretest
Clinical Score (4 T's) for the Diagnosis of Heparin-Induced Thrombocytopenia in Two Clinical Settings.
Journal of Thrombosis and Haemostasis, 4, 759-765.
http://dx.doi.org/10.1111/j.1538-7836.2006.01787.x
[19] Duplaga, B., Rivers, C. and Nutescu, E. (2001). Dosing and Monitoring of Low-Molecular-Weight Heparins
in Special Populations. Pharmacotherapy, 21, 218-234. http://dx.doi.org/10.1592/phco.21.2.218.34112
[20] King, C., Holley, A., Jackson, J., Shorr, A. and Moores, L. (2007) Twice Daily vs Three Times Daily Heparin Dosing for Thromboembolism Prophylaxis in the General Medical Population. CHEST, 131, 507-516.
http://dx.doi.org/10.1378/chest.06-1861
[21] Nutescu, E., Spinler, S., Wittkowsky, A. and Dager, W. (2009) Low-Molecular-Weight Heparins in
Renal Impairment and Obesity: Available Evidence and Clinical Practice Recommendations across
Medical and Surgical Settings. Annals of Pharmacotherapy, 43, 1064-1083.
http://dx.doi.org/10.1345/aph.1L194
[22] Phung, O., Kahn, S., Cook, D. and Murad, M. (2011) Dosing Frequency of Unfractionated Heparin Thromboprophylaxis: A Meta-Analysis. CHEST, 140, 374-381.
http://dx.doi.org/10.1378/chest.10-3084
[23] Scholten, D., Hoedema, R. and Scholten, S. (2002) A Comparison of Two Different Prophylactic Dose
Regimens of Low Molecular Weight Heparin in Bariatric Surgery. Obesity Surgery, 12, 19-24.
http://dx.doi.org/10.1381/096089202321144522
[24] Enoxaparin. In: DRUGDEX® System (internet database). Thomson Micromedex, Greenwood Village,
Colorado, USA. http://www.thomsonhc.com
[25] Enoxaparin: Drug information. (2013).
http://www.uptodate.com/contents/enoxaparin-drug-information?source=search_result&search=enoxaparin&selectedTitle=1%7E96

  
comments powered by Disqus

Copyright © 2020 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.