Obesity

Lmwh dose obesity: Treatment of Venous Thromboembolism in Patients Who Are Morbidly Obese

Volume 4, Issue Each episode of suspected recurrent VTE was investigated by repeat compression ultrasonography, lung scan, computed tomographic pulmonary angiography or pulmonary angiography, as chosen by the treating physician.

Substances Anticoagulants Enoxaparin. Manuel MonrealManuel Lmwh dose obesity. Uncapped dose. The optimal dose of LMWH therapy for obese patients with acute VTE is guided by limited pharmacokinetic data with no substantiating clinical data. Mark CrowtherMark Crowther.

  • Navigate this Article. Background: Enoxaparin is a low-molecular weight heparin LMWH commonly used for treatment of venous thromboembolism and acute coronary syndromes.

  • Table 1.

  • Secondary outcomes were bleeding and thromboembolic events.

  • The concern regarding uncapped doses is the subtherapeutic anticoagulant effect resulting in otherwise avoidable thromboembolisms. However, we did not have sufficient power to test statistically for interaction of dosing strategy with metastatic cancer.

MeSH terms

In Reply: We thank Drs. All materials will be made available on e-mail request to the corresponding author. Available evidence supports the potential for enoxaparin accumulation, but not tinzaparin.

  • Table 7. Table 6.

  • View Large. Jared P.

  • Unadjusted rates of lmwh dose obesity primary and secondary outcomes were calculated during LMWH therapy. If a vitamin K antagonist and bridging with LMWH is used, it is also important to note the limited data and different pharmacokinetic and pharmacodynamic properties in patients who are morbidly obese.

  • Multivariable analysis confirmed that patients who received capped doses had significantly lower rates of the composite outcome odds ratio, 0. The breakdown of weights between groups is reported in Table 3.

  • Lovenox enoxaparin sodium product monograph.

  • This study has several significant limitations, broadly categorized as risk of significant bias and problems relating to the analysis. Multivariable logistic regression analysis was used to account for possible confounders.

Sign Up Now. Relatively few patients 4. Figure 1. Robby NieuwlaatRobby Nieuwlaat.

Details of therapy. Doae see the full article, log in or purchase access. Use of capped vs uncapped LMWH doses according to body weight. Jared P. Multivariable analysis confirmed that patients who received capped doses had significantly lower rates of the composite outcome odds ratio, 0. In Reply: We thank Drs.

Key Points

View large Download slide. Abstract Superior bioavailability and simple weight-based doee have made low-molecular-weight heparins LMWH the preferred agents for treatment and prevention of venous thromboembolism VTE for most indications. Patient demographics and treatment variables. Our results are potentially valuable, however, as they suggest that capped dosing may have a role in obese patients with VTE who are at high risk for bleeding. Mean standard deviation LMWH treatment duration was

  • The influence of extreme body weight on clinical outcome of patients with venous thromboembolism: findings from a prospective registry RIETE.

  • We prespecified that patients with metastatic cancer would have a higher risk of death, thrombosis, and bleeding. Higher doses could cause both more bleeding and decreased VTE, reducing the value of this composite end point.

  • Sign In. Randomized comparison of low molecular weight heparin and coumarin derivatives on the survival of patients with cancer and venous thromboembolism.

Mean treatment duration was Apr 15, Issue. J Thromb Haemost. During the first 15 ,mwh of anticoagulant therapy including events not attributable to LMWH by our rule11 patients 0. After adjustment for multiple potential confounders, patients with obesity who were receiving capped doses were at a lower risk of having the composite outcome of VTE recurrences, major bleeding, or all-cause death at 15 and 90 days. Blood Adv ; 4 11 : — Purchase Access: See My Options close.

Publication types Review. During each visit, any signs or symptoms suggesting VTE recurrences or major bleeding dpse noted. The optimal dose of LMWH therapy for obese patients with acute VTE is guided by limited pharmacokinetic data with no substantiating clinical data. Cited By Web Of Science 1. There were no bleeding events. Possible conflicts of interest must be disclosed at time of submission. Table 1.

The editors may edit letters to meet style and space requirements. Despite our attempt to control obesty these potential confounders in multivariable analysis, residual confounding may partially explain the lmwh dose in outcomes between capped and uncapped dosing. Of the variables included, 3 had missing data: concomitant antiplatelets missing values and platelet and hemoglobin count 3 missing values for both counts. Dosing of LMWH by body weight in patients with obesity may lead to increased rates of the composite of bleeding, VTE recurrence, and death. Send letters to afplet aafp.

Letters to the Editor

Only the first event in a single individual was counted toward the composite, lmwh dose obesity the sum of individual events do not match the total. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Unadjusted outcome rates revealed that capped dosing was associated with a decrease in the composite outcome rate ratio, 0. Blood Adv 4 11 : —

Contact afpserv aafp. Skip Nav Destination Content Menu. Unadjusted outcome rates lmwh dose obesity vs capped dosing at 15 days in patients initiated on LMWH and transitioned to other agents. Third, outcome events were not adjudicated centrally. Finally, our composite analysis assumed that an episode of VTE, a major bleeding episode, and all-cause death had equal value.

Of the variables included, 3 had missing data: concomitant antiplatelets missing values and platelet and hemoglobin count 3 missing values for both counts. Monitoring enoxaparin with antifactor xa levels in obese patients. Close Key Points. Figure 1.

Letters to the Editor

In addition, patients who received capped doses of LMWH were more likely to be prescribed tinzaparin or obesitt, but less likely to receive enoxaparin, and were also less likely to have concomitant therapy with antiplatelets Table 2. Continuing the direct oral anticoagulant is reasonable if the level falls within the expected range, but changing to a vitamin K antagonist is recommended, if possible, if the drug level is below the therapeutic range. Patient demographics and treatment variables. Patients who received capped doses were slightly older For patients with a BMI greater than 40 kg per m 2 or weight more than kg, direct oral anticoagulants should not be considered a first-line therapy because of limited clinical data and evidence suggesting decreased exposure, concentration, and half-lives at the weight extremes.

However, the International Society on Thrombosis and Haemostasis suggests that for patients who are morbidly obese who cannot use a vitamin K antagonist warfarin [Coumadin]physicians might consider checking anti—factor Xa peak and trough levels obesihy apixaban [Eliquis], edoxaban [Savaysa], and rivaroxaban rose. Unadjusted outcome rates uncapped vs capped dosing at 15 days in patients initiated on LMWH and transitioned to other agents. Despite our attempt to control for these potential confounders in multivariable analysis, residual confounding may partially explain the difference in outcomes between capped and uncapped dosing. Assessing an enoxaparin dosing protocol in morbidly obese patients. The breakdown of weights between groups is reported in Table 3. Although monitoring peaks and troughs in anti—factor Xa levels in patients who are morbidly obese and treated with factor Xa inhibitors may help safely guide therapy in this population, these laboratory assays are not readily available to most family physicians.

  • The concern regarding uncapped doses is the subtherapeutic anticoagulant effect resulting in otherwise avoidable thromboembolisms.

  • Sign In.

  • A maximum unit threshold that is the same across each drug and dose strategy means that the weights at which a dose should be defined as capped vs not capped can vary, as would the pharmacologic effects.

  • Publication types Review.

Unadjusted outcome rates uncapped vs capped lmwh dose obesity in patients with metastatic cancer. Earn up to 6 CME credits per issue. Already a member or subscriber? Contribution: R. Close Key Points. Rick IkesakaRick Ikesaka. Events per patient-years.

Robby NieuwlaatRobby Nieuwlaat. Table 5. To the Editor: We read the article on venous thromboembolism VTE with interest and appreciate that the authors highlight the different treatment options for this disease state. Am Fam Physician.

Publication types

View Large. Juan J. Most outcomes were classified as reported by the clinical centers; there was no central adjudication of outcome events.

Table 6 includes detailed outcomes for this subgroup. These retrospective observational data suggest that capped dosing of LMWH is an acceptable alternative to uncapped dosing based on body weight, given the significantly lower composite event rate of VTE recurrence, major bleeding, and all-cause death. Publication types Review. Supplemental data Supplement File 1 - pdf file. Lovenox enoxaparin sodium product monograph. Volume 4, Issue

Capped dose. Letters submitted for publication in AFP must not be submitted to any other publication. However, the International Society on Thrombosis and Haemostasis suggests that for patients who are morbidly obese who cannot use a vitamin K antagonist warfarin [Coumadin]physicians might consider checking anti—factor Xa peak and trough levels for apixaban [Eliquis], edoxaban [Savaysa], and rivaroxaban [Xarelto]. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Renal insufficiency is a risk for bleeding during LMWH use. Cite Icon Cite.

We agree that direct oral anticoagulant use in patients with a Mesomorph body type male obese greater than 40 kg per l,wh 2 has not been adequately studied and should be avoided. The drug, dose, and duration of therapy were recorded. Cumulative rates of composite outcome VTE, major bleeding, or death during the first 30 days of LMWH therapy uncapped vs capped dosing. Include your complete address, e-mail address, and telephone number. Contribution: R. Robby NieuwlaatRobby Nieuwlaat.

Table 6 includes detailed outcomes for this subgroup. Email Alerts Don't miss a single issue. Arnav AgarwalArnav Agarwal. Table 2. New Journal Content Alert.

View Metrics. Because of the absence of comparative evidence, current guidelines and product lkwh diverge in the dosing of low-molecular-weight heparin LMWH for obese patients with venous thromboembolism VTE. Article Navigation. It should be noted that all data regarding anti— factor Xa levels used tests specifically calibrated for the drug being tested or mass spectrometry drug levels. Arnav AgarwalArnav Agarwal. After adjustment for multiple potential confounders, patients with obesity who were receiving capped doses were at a lower risk of having the composite outcome of VTE recurrences, major bleeding, or all-cause death at 15 and 90 days. Background: Enoxaparin is a low-molecular weight heparin LMWH commonly used for treatment of venous thromboembolism and acute coronary syndromes.

Figure 1. To see the full article, log in or purchase access. Jared P. Supplemental data Supplement File 1 - pdf file. The lmwh dose obesity of extreme body weight on clinical outcome of patients with venous thromboembolism: findings from a prospective registry RIETE. Conflict-of-interest disclosure: R. Indeed, our findings are consistent with a meta-analysis of the bariatric surgery literature suggesting higher rates of bleeding episodes, without reduction in rates of VTE, using weight-adjusted heparin prophylaxis dosing.

Key Points

View large Download slide. Unadjusted outcome rates uncapped vs capped dosing at 15 days in patients initiated on LMWH and transitioned to other agents. Best Value! Elvira GrandoneElvira Grandone. Visual Abstract View large Download slide.

View Metrics. In Reply: We thank Drs. Second, there were several prognostic differences at baseline between the 2 groups: patients receiving capped doses were significantly more likely to obesity dode and metastatic cancer, to weigh less, and to have DVT vs PE and were significantly less likely to have received concomitant antiplatelet therapy. Few recommendations can be made in this population other than close monitoring. Trends in obesity among adults in the United States, to Higher doses could cause both more bleeding and decreased VTE, reducing the value of this composite end point. Visual Abstract View large Download slide.

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Patients were treated according to the clinical practice of each lmwwh hospital ie, there was no standardized therapy. Higher doses could cause both more bleeding and decreased VTE, reducing the value of this composite end point. Already a member or subscriber? Renal insufficiency presents a risk of LMWH accumulation as well as increased risk of bleeding. In addition, patients who received capped doses of LMWH were more likely to be prescribed tinzaparin or dalteparin, but less likely to receive enoxaparin, and were also less likely to have concomitant therapy with antiplatelets Table 2. Include your complete address, e-mail address, and telephone number. Patients were followed up for a median of days and a mean of days, respectively.

  • Get immediate access, anytime, anywhere. Similarly, deaths were considered attributable to LMWH therapy if they occurred during therapy or within 7 days of treatment discontinuation.

  • Major bleeding was defined as overt bleeding requiring a transfusion of 2 or more units of blood or retroperitoneal, spinal, intracranial, or fatal bleeding episodes. Patients treated with thrombolytics were excluded from analysis.

  • During the first 15 days of anticoagulant therapy including events not attributable to LMWH by our rule11 patients 0.

  • The International Society on Thrombosis and Haemostasis offers some guidance.

  • Capped dose.

This effect was mainly due to a trend toward lower rates of unadjusted major bleeding: no episodes in the capped-dose group vs 24 in the uncapped-dose group Figure 1. In obese individuals with disproportionately more adipose tissue, there is a concern about overdose and bleeding when treatment with standard dosing by actual body weight is applied. To see the full article, log in or purchase access. Results: Two hundred forty-one patients were included in the study, and achieved a therapeutic dose. Potential confounders were entered into the multivariable model based on associations from the literature. During each visit, any signs or symptoms suggesting VTE recurrences or major bleeding were noted.

Bridgewater, N. There were no bleeding events. Capped dose. Juan J. Third, outcome events were not adjudicated centrally. Patients were followed up in the outpatient clinic or by telephone interview if they could not visit the clinic.

This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in obesity medium, whether now known or later invented, except as authorized in writing by the AAFP. Assessing an enoxaparin dosing protocol in morbidly obese patients. Sign Up Now.

  • Close Key Points.

  • Patients were followed up in the outpatient clinic or by telephone interview if they could not visit the clinic. Cite Icon Cite.

  • The influence of extreme body weight on clinical outcome of patients with venous thromboembolism: findings from a prospective registry RIETE.

  • Lovenox enoxaparin sodium product monograph. Elvira GrandoneElvira Grandone.

Obese patients have a lower proportion of lean body mass as a percentage of total body weight. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. Apr 15, Issue. If a vitamin K antagonist and bridging with LMWH is used, it is also important to note the limited data and different pharmacokinetic and pharmacodynamic properties in patients who are morbidly obese.

Our lmwh dose obesity to include up to 3 days after discontinuation was based on 3 factors: 1 there may be a delay in the diagnosis of bleeding; 2 the half-life of LMWH is increased when the glomerular filtration rate is reduced; 3 doses in this population are at and above the upper limits of the studied doses and therefore may be associated with altered kinetics and dynamics. Third, outcome events were not adjudicated centrally. Ours is the first study to compare these 2 therapeutic LMWH dosing strategies on the basis of patient-important clinical outcomes. Reza MirzaReza Mirza. We agree that direct oral anticoagulant use in patients with a BMI greater than 40 kg per m 2 has not been adequately studied and should be avoided.

Boesity your lmwh dose obesity address, e-mail address, and telephone number. Log in. Email alerts Article Activity Alert. Conflict-of-interest disclosure: R. The following variables were entered as potential confounders: age, sex, history of chronic heart or lung disease, recent immobility, cancer, metastatic cancer, recent major bleeding, anemia, thrombocytopenia, renal insufficiency, initial presentation of VTE, type of LMWH used for initial therapy, concomitant therapy with antiplatelets, and long-term therapy with vitamin K antagonists.

Table 6 includes detailed outcomes for this subgroup. Email alerts Article Activity Alert. Visual Abstract View large Download slide.

A person viewing it online may make one printout of the material and may use that printout lmwh dose obesity for his or her personal, non-commercial reference. Major bleeding was defined as overt bleeding requiring a transfusion of 2 or more units of blood or retroperitoneal, spinal, intracranial, or fatal bleeding episodes. Unadjusted rates of the primary and secondary outcomes were calculated during LMWH therapy. Our results are potentially valuable, however, as they suggest that capped dosing may have a role in obese patients with VTE who are at high risk for bleeding. Lawrence M. To our knowledge, there are no data in the literature that compare rates of clinical events in obese patients with VTE treated with capped vs uncapped doses.

Gibbs and Sheley for raising an important issue regarding our article. These retrospective observational data suggest that capped dosing of LMWH is lmwh dose obesity acceptable alternative to uncapped dosing based on body weight, given the significantly lower composite event kbesity of Ovesity recurrence, major bleeding, and all-cause death. Cardiovascular risk factors and venous thromboembolism incidence: the longitudinal investigation of thromboembolism etiology. Concerns about underdosing and the serious consequences of therapeutic failure are cited as justification for the recommendation. Despite our attempt to control for these potential confounders in multivariable analysis, residual confounding may partially explain the difference in outcomes between capped and uncapped dosing. Adipokines are associated with lower extremity venous disease: the San Diego population study. Binary multivariable logistic regression was used to calculate adjusted odds ratios [ORs] for the association of treatment capped vs uncapped with the primary composite outcome during LMWH therapy and also at 15 days from initiation of therapy regardless of transition to another agent as a secondary outcome.

Accessed November 2, It should be noted that all data regarding anti— factor Xa levels used tests specifically calibrated rose the drug being tested or mass spectrometry drug levels. In terms of the multivariable analysis, there was a relatively low number of events, especially in the capped-dose group, which may have led to overfitting in multivariable analysis. Multivariable logistic regression analysis was used to account for possible confounders.

Bridgewater, N. In addition, patients who received capped doses of LMWH were more likely to be prescribed tinzaparin lmwh dose obesity dalteparin, but less likely to receive enoxaparin, and were also less likely to have concomitant therapy with antiplatelets Table 2. Letters should be fewer than words and limited to six references, one table or figure, and three authors. Randomized comparison of low molecular weight heparin and coumarin derivatives on the survival of patients with cancer and venous thromboembolism.

Blood Adv ; 4 11 : — Read the Issue. Contribution: R. Purchase Access: See My Options close.

Doose disclosure: R. Because of the absence of comparative evidence, current guidelines and product monographs diverge in the dosing of low-molecular-weight heparin LMWH for obese patients with venous thromboembolism VTE. Mean standard deviation LMWH treatment duration was Contribution: R. Two events were counted in the capped-dose group: 2 PEs 0.

Navigate this Article. View Metrics. Arnav AgarwalArnav Agarwal. Among LMWH products, only dalteparin labeling recommends a maximum dose. Fragmin dalteparin sodium product monograph. Sheley, PharmD Edwardsville, Ill. Our results are potentially valuable, however, as they suggest that capped dosing may have a role in obese patients with VTE who are at high risk for bleeding.

Continuing the direct oral anticoagulant is reasonable if the level falls within the expected range, but changing to a vitamin K antagonist is recommended, if possible, if the drug level is below the therapeutic range. Article Navigation. Conflict-of-interest disclosure: R.

Gibbs and Sheley for raising an important issue regarding our article. Article history Submitted:. Letters submitted for publication in AFP must not be submitted to any other publication. Rick IkesakaRick Ikesaka. Abstract Background: Enoxaparin is a low-molecular weight heparin LMWH commonly used for treatment of venous thromboembolism and acute coronary syndromes. Conflict-of-interest disclosure: R. Sign Up Now.

  • Sign In or Create an Account. There were no bleeding events.

  • During each visit, any signs or symptoms suggesting VTE recurrences or major bleeding were noted.

  • In Reply: We thank Drs. Patients were followed up for a median of days and a mean of days, respectively.

  • Reza MirzaReza Mirza.

Indeed, our doe are consistent with a meta-analysis of the bariatric surgery literature suggesting higher rates of bleeding episodes, without reduction in rates of VTE, using weight-adjusted heparin prophylaxis dosing. Our concern in specifying a minimum for treatment duration was the risk of excluding patients who experienced adverse events and therefore had LMWH discontinued. Close Key Points. Despite our attempt to control for these potential confounders in multivariable analysis, residual confounding may partially explain the difference in outcomes between capped and uncapped dosing. Venous thromboembolism after laparoscopic bariatric surgery for morbid obesity: clinical burden and prevention.

American Society of Hematology guidelines lmwh dose obesity lmqh of venous thromboembolism: optimal management of anticoagulation therapy. Secondary outcomes were bleeding and thromboembolic events. Most outcomes were classified as reported by the clinical centers; there was no central adjudication of outcome events. Third, outcome events were not adjudicated centrally. Although monitoring peaks and troughs in anti—factor Xa levels in patients who are morbidly obese and treated with factor Xa inhibitors may help safely guide therapy in this population, these laboratory assays are not readily available to most family physicians.

Article Navigation. Robby NieuwlaatRobby Nieuwlaat. Results: Two hundred forty-one patients were included in the study, and achieved a therapeutic dose.

Unadjusted outcome rates uncapped vs capped dosing in patients with metastatic cancer. Article Navigation. Author notes The full-text version of this article contains a data supplement. Sign In. Patients were treated according to the clinical practice of each participating hospital ie, there was no standardized therapy. LMWHs are hydrophilic and therefore largely remain in the intravascular compartment. Venous thromboembolism after laparoscopic bariatric surgery for morbid obesity: clinical burden and prevention.

All patients or their relatives provide written or oral consent for lmwh dose obesity in the registry, in obesitty with local ethics committee requirements. During the first 15 days of anticoagulant therapy including events not attributable to LMWH by our rule11 patients 0. Despite our attempt to control for these potential confounders in multivariable analysis, residual confounding may partially explain the difference in outcomes between capped and uncapped dosing. Close Key Points. Mean treatment duration was Lawrence M.

Robby NieuwlaatRobby Nieuwlaat. The concern regarding uncapped doses is the subtherapeutic anticoagulant effect resulting in otherwise avoidable thromboembolisms. Sign Up Now. However, the International Society on Thrombosis and Haemostasis suggests that for patients who are morbidly obese who cannot use a vitamin K antagonist warfarin [Coumadin]physicians might consider checking anti—factor Xa peak and trough levels for apixaban [Eliquis], edoxaban [Savaysa], and rivaroxaban [Xarelto]. Our decision to include up to 3 days after discontinuation was based on 3 factors: 1 there may be a delay in the diagnosis of bleeding; 2 the half-life of LMWH is increased when the glomerular filtration rate is reduced; 3 doses in this population are at and above the upper limits of the studied doses and therefore may be associated with altered kinetics and dynamics. Supplemental data Supplement File 1 - pdf file. Cite Icon Cite.

Venous thromboembolism after laparoscopic bariatric obesity for morbid obesity: clinical burden and prevention. Boesity MonrealManuel Monreal. The secondary outcome was the composite outcome at 15 days, whether the patient had transitioned from LMWH to another anticoagulant or not. As physicians were aware of treatment allocation, it is possible that their knowledge of dosage influenced their reporting of clinical events.

Table 4. Adipokines are associated with lower extremity venous disease: the San Diego population study. Few recommendations can be made in this population other than close monitoring. The drug, dose, and duration of therapy were recorded. Our results are potentially valuable, however, as they suggest that capped dosing may have a role in obese patients with VTE who are at high risk for bleeding.

Venous thromboembolism after laparoscopic bariatric surgery for morbid obesity: clinical burden and prevention. Table 6 includes detailed outcomes for this subgroup. Few recommendations can be made in this population other than close monitoring. Skip Nav Destination Content Menu. J Thromb Thrombolysis.

This is the first study to compare clinical outcomes of treatment dosing strategies for LMWH in patients with obesity. Fatal bleeding in patients receiving anticoagulant therapy for venous thromboembolism: findings from the RIETE registry. These retrospective observational data suggest that capped dosing of LMWH is an acceptable alternative to uncapped dosing based on body weight, given the significantly lower composite event rate of VTE recurrence, major bleeding, and all-cause death. Table 1. The secondary outcome was the composite outcome at 15 days, whether the patient had transitioned from LMWH to another anticoagulant or not.

Mean treatment duration was Cited By Web Of Science 1. Jared P. Continuous Publishing Alert.

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A maximum unit threshold that is the same across each drug and dose strategy means that lmwh dose obesity weights at which a dose should be defined as capped vs not capped can vary, as would the pharmacologic effects. Sign Up Now. Reza MirzaReza Mirza. Sheley, PharmD Edwardsville, Ill. This study has several significant limitations, broadly categorized as risk of significant bias and problems relating to the analysis.

This effect was mainly due to a trend toward lower rates of unadjusted major bleeding: no episodes in the capped-dose group vs 24 in the uncapped-dose group Figure 1. Raquel BarbaRaquel Barba. J Thromb Thrombolysis. The drug, dose, and duration of therapy were recorded.

Reza MirzaReza Mirza. View Metrics. Close Key Points.

  • Finally, our composite analysis assumed that an episode of VTE, a major bleeding episode, and all-cause death had equal value.

  • Letters should be fewer than words and limited to six references, one table or figure, and three authors.

  • Close Modal.

  • Of the variables included, 3 had missing data: concomitant antiplatelets missing values and platelet and hemoglobin count 3 missing values for both counts.

Lovenox enoxaparin sodium product monograph. Reza MirzaReza Mirza. Patients treated with thrombolytics were excluded from analysis. View Large.

LMWHs are hydrophilic and therefore largely remain in the intravascular compartment. Gibbs and Sheley for dlse lmwh dose obesity important issue regarding our article. It should be noted that all data regarding anti— factor Xa levels used tests specifically calibrated for the drug being tested or mass spectrometry drug levels. Patients were treated according to the clinical practice of each participating hospital ie, there was no standardized therapy.

Forty-nine total events were attributable to LMWH therapy, according to the prespecified rule of obesigy events if they occurred within 3 or 7 days of discontinuation Table 4. View large Download slide. The lmwh dose of weights between groups is reported in Table 3. Our decision to include up to 3 days after discontinuation was based on 3 factors: 1 there may be a delay in the diagnosis of bleeding; 2 the half-life of LMWH is increased when the glomerular filtration rate is reduced; 3 doses in this population are at and above the upper limits of the studied doses and therefore may be associated with altered kinetics and dynamics. View Large.

Finally, our composite analysis assumed that an episode of VTE, a lmwh dose bleeding episode, and all-cause death had equal value. Given the higher percentage of patients with active and metastatic cancer in the capped-dose group and the lower unadjusted event rates in the group, it seems improbable that capped dosing is harmful in either subgroup. Letters submitted for publication in AFP must not be submitted to any other publication. Cumulative rates of composite outcome VTE, major bleeding, or death during the first 30 days of LMWH therapy uncapped vs capped dosing. The editors may edit letters to meet style and space requirements.

  • As physicians were aware of treatment allocation, it is possible that their knowledge of dosage influenced their reporting of clinical events.

  • The editors may edit letters to meet style and space requirements.

  • Mean treatment duration was

  • Capped dose.

Our concern in specifying a minimum for treatment duration was the risk of excluding patients who experienced adverse events and therefore had LMWH discontinued. Abstract Superior bioavailability and simple weight-based dosing have made low-molecular-weight heparins LMWH the preferred agents for treatment and prevention of venous thromboembolism VTE for most indications. View Metrics. Blood Adv 4 11 : — Figure 1.

Maurizio CiammaichellaMaurizio Ciammaichella. New Journal Content Alert. Our results are potentially valuable, however, as they suggest that capped dosing may have a role in obese patients with VTE who are at high risk for bleeding. Sign Up Now. Blood Adv 4 11 : — In obese individuals with disproportionately more adipose tissue, there is a concern about overdose and bleeding when treatment with standard dosing by actual body weight is applied. Supplemental data Supplement File 1 - pdf file.

Get immediate access, anytime, anywhere. Accessed November 2, The remaining authors declare no competing financial interests. Am Fam Physician.

Patients treated with thrombolytics were lmwh dose obesity from analysis. It should be noted that all data regarding anti— factor Xa levels used tests specifically calibrated for the drug being tested or mass spectrometry drug levels. Jared P. Bridgewater, N. Lawrence M. Abstract Background: Enoxaparin is a low-molecular weight heparin LMWH commonly used for treatment of venous thromboembolism and acute coronary syndromes.

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Second, obesith were several prognostic differences at baseline between the 2 groups: patients receiving capped doses were significantly more likely to have active and metastatic cancer, to weigh less, and to have DVT vs PE and were significantly less likely to have received concomitant antiplatelet therapy. Rick IkesakaRick Ikesaka. Conflict-of-interest disclosure: R. Potential confounders were entered into the multivariable model based on associations from the literature. Prospective data evaluating LMWH use in elderly patients have been limited to in-patient treatment. Visual Abstract View large Download slide.

Gibbs and Sheley for raising an important issue regarding our article. Our concern in specifying a minimum for treatment duration was the risk of excluding patients who experienced adverse events and therefore had LMWH discontinued. Multivariable analysis confirmed that patients who received capped doses had significantly lower rates of the composite outcome odds ratio, 0. Unadjusted outcome rates revealed that capped dosing was associated with a decrease in the composite outcome rate ratio, 0. Blood Adv ; 4 11 : —

J Thromb Thrombolysis. Similarly, deaths were considered attributable to LMWH therapy if they occurred during therapy or within lmwh dose obesity days of treatment discontinuation. Log in Best Value! To our knowledge, there are no data in the literature that compare rates of clinical events in obese patients with VTE treated with capped vs uncapped doses.

Bridgewater, Obsity. Ours is the first study to compare these 2 therapeutic LMWH dosing lmwh dose obesity on the basis of patient-important clinical outcomes. Manuel MonrealManuel Monreal. The editors may edit letters to meet style and space requirements. Table 7. Possible conflicts of interest must be disclosed at time of submission. Table 1.

  • Table 3. To our knowledge, there are no data in the literature that compare rates of clinical events in obese patients with VTE treated with capped vs uncapped doses.

  • Lawrence M.

  • View large Download PPT.

  • Close Key Points.

Lmwh dose obesity is the first study to compare clinical outcomes of treatment dosing strategies for LMWH in patients with obesity. Read the Issue. This content is owned by the AAFP. Ours is the first study to compare these 2 therapeutic LMWH dosing strategies on the basis of patient-important clinical outcomes. Want to use this article elsewhere?

Two obesity were counted in the capped-dose group: 2 PEs obseity. Conclusion: Standard dosing of enoxaparin in morbidly obese patients will most likely lead to supratherapeutic anti-Xa levels and thus further investigation is warranted to better determine appropriate dosing. Assessing an enoxaparin dosing protocol in morbidly obese patients. Third, outcome events were not adjudicated centrally. Apr 15, Issue. Conflict-of-interest disclosure: R. Patients were followed up in the outpatient clinic or by telephone interview if they could not visit the clinic.

Apr 15, Issue. Third, outcome events were not adjudicated centrally. Mark CrowtherMark Mesomorph body type male obese. In obese individuals with disproportionately more adipose tissue, there is a concern about overdose and bleeding when treatment with standard dosing by actual body weight is applied.

Carme FontCarme Font. References show all references 1. However, we did not have mesomorph body type male obese power pmwh test statistically for interaction of dosing strategy with metastatic cancer. Adipokines are associated with lower extremity venous disease: the San Diego population study. The breakdown of weights between groups is reported in Table 3.

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There were no bleeding events. New Journal Content Alert. Already a member or subscriber? The mesomorph body type male obese of weights between groups is reported in Table 3. Cited By Web Of Science 1. American Society of Hematology guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy.

Each episode of suspected recurrent VTE was investigated by repeat compression ultrasonography, lung scan, computed tomographic pulmonary angiography or pulmonary angiography, as chosen by the treating physician. Because of the absence of comparative obesiyy, current guidelines and product monographs diverge in the dosing of low-molecular-weight heparin LMWH for obese patients with venous thromboembolism VTE. Jared P. Conflict-of-interest disclosure: R. For patients with a BMI greater than 40 kg per m 2 or weight more than kg, direct oral anticoagulants should not be considered a first-line therapy because of limited clinical data and evidence suggesting decreased exposure, concentration, and half-lives at the weight extremes. These retrospective observational data suggest that capped dosing of LMWH is an acceptable alternative to uncapped dosing based on body weight, given the significantly lower composite event rate of VTE recurrence, major bleeding, and all-cause death.

Read the full article. These retrospective observational data suggest that capped dosing of LMWH obseity an acceptable alternative to uncapped dosing based obesity body weight, given the significantly lower composite event rate of VTE recurrence, major bleeding, and all-cause death. E-mail: lawrencegibbs mhd. Finally, our composite analysis assumed that an episode of VTE, a major bleeding episode, and all-cause death had equal value. View Metrics. After adjustment for multiple potential confounders, patients with obesity who were receiving capped doses were at a lower risk of having the composite outcome of VTE recurrences, major bleeding, or all-cause death at 15 and 90 days. Assessing an enoxaparin dosing protocol in morbidly obese patients.

Maurizio CiammaichellaMaurizio Ciammaichella. Lmwh dose obesity of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. However, the International Society on Thrombosis and Haemostasis suggests that for patients who are morbidly obese who cannot use a vitamin K antagonist warfarin [Coumadin]physicians might consider checking anti—factor Xa peak and trough levels for apixaban [Eliquis], edoxaban [Savaysa], and rivaroxaban [Xarelto]. Table 3.

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  • The decision on the type lmwh dose obesity duration of anticoagulant therapy was left to the attending physicians. Dosing of LMWH by body weight in patients with obesity may lead to increased rates of the composite of bleeding, VTE recurrence, and death.

  • There were no bleeding events. Best Value!

Log in. Robby NieuwlaatRobby Nieuwlaat. Our concern in specifying a minimum for treatment duration was the risk of excluding patients who experienced obestiy events and therefore had LMWH discontinued. A maximum unit threshold that is the same across each drug and dose strategy means that the weights at which a dose should be defined as capped vs not capped can vary, as would the pharmacologic effects. Table 5. This effect was mainly due to a trend toward lower rates of unadjusted major bleeding: no episodes in the capped-dose group vs 24 in the uncapped-dose group Figure 1. Use of capped vs uncapped LMWH doses according to body weight.

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However, doose International Society on Thrombosis and Haemostasis suggests that for patients who are morbidly obese who cannot use a vitamin K antagonist obesity [Coumadin]physicians might consider checking anti—factor Xa peak and trough levels for apixaban [Eliquis], edoxaban [Savaysa], and rivaroxaban [Xarelto]. For patients with a BMI greater than 40 kg per m 2 or weight more than kg, direct oral anticoagulants should not be considered a first-line therapy because of limited clinical data and evidence suggesting decreased exposure, concentration, and half-lives at the weight extremes. The influence of extreme body weight on clinical outcome of patients with venous thromboembolism: findings from a prospective registry RIETE. This study has several significant limitations, broadly categorized as risk of significant bias and problems relating to the analysis. Want to use this article elsewhere? Continuous Publishing Alert. Article Navigation.

Obeskty multivariable logistic regression was used to calculate lmwh dose obesity odds ratios [ORs] for the association of treatment capped vs uncapped with the primary composite outcome during LMWH therapy and also at 15 days from initiation of therapy regardless of transition to another agent as a secondary outcome. In obese individuals with disproportionately more adipose tissue, there is a concern about overdose and bleeding when treatment with standard dosing by actual body weight is applied. Raquel BarbaRaquel Barba. Article history Submitted:.

Trends in obesity among adults in the United States, to obesity In our experience, treatment of dlse VTE in patients who are morbidly obese is most safely achieved by using intravenous unfractionated heparin and concomitant warfarin. Cumulative rates of composite outcome VTE, major bleeding, or death during the first 30 days of LMWH therapy uncapped vs capped dosing. Want to use this article elsewhere? Continuing the direct oral anticoagulant is reasonable if the level falls within the expected range, but changing to a vitamin K antagonist is recommended, if possible, if the drug level is below the therapeutic range. Use of capped vs uncapped LMWH doses according to body weight. Most outcomes were classified as reported by the clinical centers; there was no central adjudication of outcome events.

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