Dosing practice of low molecular weight heparins and its efficacy and safety in cardiovascular inpatients: a retrospective study in a Chinese teaching hospital

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• 作者：Huimin Xu (1)
  Hongwen Cai (2)
  Zhongshu Qian (1)
  Geng Xu (3)
  Xiaofeng Yan (1)
  Haibin Dai (1)
  
• 关键词：Low molecular weight heparin ; Dosing practice ; Cardiovascular inpatients ; Efficacy ; Safety
• 刊名：BMC Cardiovascular Disorders
• 出版年：2012
• 出版时间：December 2012
• 年：2012
• 卷：12
• 期：1
• 全文大小：178KB
• 参考文献：1. Michaels AD, Spinler SA, Leeper B, Ohman EM, Alexander KP, Newby LK, Ay H, Gibler WB: Medication errors in acute cardiovascular and stroke patients: a scientific statement from the American Heart Association. / Circulation 2010,121(14):1664鈥?682. CrossRef
  2. Hirsh J, Warkentin TE, Shaughnessy SG, Anand SS, Halperin JL, Raschke R, Granger C, Ohman EM, Dalen JE: Heparin and low-molecular-weight heparin: mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy, and safety. / Chest 2001,119(1 Suppl):64S-94S. CrossRef
  3. Erkens PM, Prins MH: Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. / Cochrane Database Syst Rev 2010, (9):CD001100.
  4. Magee KD, Sevcik W, Moher D, Rowe BH: Low molecular weight heparins versus unfractionated heparin for acute coronary syndromes. / Cochrane Database Syst Rev 2003, (1):CD002132.
  5. Font MA, Krupinski J, Arboix A: Antithrombotic medication for cardioembolic stroke prevention. / Stroke Res Treat 2011, 2011:607852.
  6. Hirsh J, Raschke R: Heparin and low-molecular-weight heparin: the seventh ACCP conference on antithrombotic and thrombolytic therapy. / Chest 2004,126(3 Suppl):188S-203S. CrossRef
  7. Warkentin TE, Levine MN, Hirsh J, Horsewood P, Roberts RS, Gent M, Kelton JG: Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. / N Engl J Med 1995,332(20):1330鈥?335. CrossRef
  8. Schulman S, Beyth RJ, Kearon C, Levine MN: Hemorrhagic complications of anticoagulant and thrombolytic treatment: american college of chest physicians evidence-based clinical practice guidelines (8th edition). / Chest 2008,133(6 Suppl):257S-298S. CrossRef
  9. Cohen M, Demers C, Gurfinkel EP, Turpie AG, Fromell GJ, Goodman S, Langer A, Califf RM, Fox KA, Premmereur J, / et al.: A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease efficacy and safety of subcutaneous enoxaparin in Non-Q-wave coronary events study group. / N Engl J Med 1997,337(7):447鈥?52. CrossRef
  10. The FRAX.I.S. Study Group: Comparison of two treatment durations (6 days and 14 days) of a low molecular weight heparin with a 6-day treatment of unfractionated heparin in the initial management of unstable angina or non-Q wave myocardial infarction: FRAX.I.S. (FRAxiparine in Ischaemic Syndrome). / Eur Heart J 1999,20(21):1553鈥?562. CrossRef
  11. Klein W, Buchwald A, Hillis SE, Monrad S, Sanz G, Turpie AG, van der Meer J, Olaisson E, Undeland S, Ludwig K: Comparison of low-molecular-weight heparin with unfractionated heparin acutely and with placebo for 6 weeks in the management of unstable coronary artery disease. Fragmin in unstable coronary artery disease study (FRIC). / Circulation 1997,96(1):61鈥?8. CrossRef
  12. Bauman ME, Black KL, Bauman ML, Belletrutti M, Bajzar L, Massicotte MP: Novel uses of insulin syringes to reduce dosing errors: a retrospective chart review of enoxaparin whole milligram dosing. / Thromb Res 2009,123(6):845鈥?47. CrossRef
  13. Macie C, Forbes L, Foster GA, Douketis JD: Dosing practices and risk factors for bleeding in patients receiving enoxaparin for the treatment of an acute coronary syndrome. / Chest 2004,125(5):1616鈥?621. CrossRef
  14. Fox KA, Antman EM, Montalescot G, Agewall S, SomaRaju B, Verheugt FW, Lopez-Sendon J, Hod H, Murphy SA, Braunwald E: The impact of renal dysfunction on outcomes in the ExTRACT-TIMI 25 trial. / J Am Coll Cardiol 2007,49(23):2249鈥?255. CrossRef
  15. Alexander KP, Chen AY, Roe MT, Newby LK, Gibson CM, Allen-LaPointe NM, Pollack C, Gibler WB, Ohman EM, Peterson ED: Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. / JAMA 2005,294(24):3108鈥?116. CrossRef
  16. Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, / et al.: Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). / Eur Heart J 2010,31(19):2369鈥?429. CrossRef
  17. Lin BW, Yoshida D, Quinn J, Strehlow M: A better way to estimate adult patients' weights. / Am J Emerg Med 2009,27(9):1060鈥?064. CrossRef
  18. Anglemyer BL, Hernandez C, Brice JH, Zou B: The accuracy of visual estimation of body weight in the ED. / Am J Emerg Med 2004,22(7):526鈥?29. CrossRef
  19. Montalescot G, Collet JP, Tanguy ML, Ankri A, Payot L, Dumaine R, Choussat R, Beygui F, Gallois V, Thomas D: Anti-Xa activity relates to survival and efficacy in unselected acute coronary syndrome patients treated with enoxaparin. / Circulation 2004,110(4):392鈥?98. CrossRef
  20. Al-Sallami HS, Barras MA, Green B, Duffull SB: Routine plasma anti-Xa monitoring is required for low-molecular-weight heparins. / Clin Pharmacokinet 2010,49(9):567鈥?71. CrossRef
  21. Singer JP, Huang MY, Hui C, Blanc PD, Boettger RF, Golden J, Watkins K, Hoopes C, Leard LE: Supratherapeutic anticoagulation from low-molecular-weight heparin in lung transplant recipients. / J Heart Lung Transplant 2010,29(9):1009鈥?013. CrossRef
  22. Bazinet A, Almanric K, Brunet C, Turcotte I, Martineau J, Caron S, Blais N, Lalonde L: Dosage of enoxaparin among obese and renal impairment patients. / Thromb Res 2005,116(1):41鈥?0. CrossRef
  23. Schmid P, Fischer AG, Wuillemin WA: Low-molecular-weight heparin in patients with renal insufficiency. / Swiss Med Wkly 2009,139(31鈥?2):438鈥?52.
  24. Frydman A: Low-molecular-weight heparins: an overview of their pharmacodynamics, pharmacokinetics and metabolism in humans. / Haemostasis 1996,26(Suppl 2):24鈥?8.
  25. Jacobs DR Jr, Kroenke C, Crow R, Deshpande M, Gu DF, Gatewood L, Blackburn H: PREDICT: A simple risk score for clinical severity and long-term prognosis after hospitalization for acute myocardial infarction or unstable angina: the Minnesota heart survey. / Circulation 1999,100(6):599鈥?07. CrossRef
  26. Collet JP, Montalescot G, Fine E, Golmard JL, Dalby M, Choussat R, Ankri A, Dumaine R, Lesty C, Vignolles N, / et al.: Enoxaparin in unstable angina patients who would have been excluded from randomized pivotal trials. / J Am Coll Cardiol 2003,41(1):8鈥?4. CrossRef
  27. Schmid P, Brodmann D, Odermatt Y, Fischer AG, Wuillemin WA: Study of bioaccumulation of dalteparin at a therapeutic dose in patients with renal insufficiency. / J Thromb Haemost 2009,7(10):1629鈥?632. CrossRef
  28. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/12/118/prepub
  
• 作者单位：Huimin Xu (1)
  Hongwen Cai (2)
  Zhongshu Qian (1)
  Geng Xu (3)
  Xiaofeng Yan (1)
  Haibin Dai (1)
  
  1. Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
  2. Department of Cardiovascular Medicine, First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, 310006, China
  3. Department of Cardiovascular Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
  

文摘

Background Low-molecular-weight heparins (LMWHs) are safe and effective anticoagulant options for cardiovascular patients when applied as body weight-adjusted doses. However, there are some barriers that make it difficult to implement weight-adjusted doses in clinical practice. Therefore, it is vital to learn the dosing practices of LMWH and its efficacy and safety in clinical practice. Methods A retrospective study was conducted in cardiovascular inpatients who had received at least one dose of LMWH during a 6-month period. Appropriateness of LMWH dosing was determined and major clinical outcomes (major adverse vascular events and major bleeding) during hospitalization were evaluated. Results A total of 376 admissions representing 364 patients received LMWH treatment. Of these, 17.0% (64/376) of admissions did not have body weight records. Of the 312 admissions included for the outcome study, only 34 cases (10.9%) received the recommended doses of LMWH, while 51 cases (16.3%) received mild underdoses, 223 cases (71.5%) received major underdoses and 4 (1.3%) received excess doses. There were 10 major adverse vascular events, which occurred more often in patients receiving excess doses of LMWH than in patients receiving recommended, mild or major underdoses (50%, 2.9%, 2.0% and 2.7%, respectively, P < 0.001). After multivariable analysis, severe renal insufficiency was an independent risk factor for major adverse vascular events [odds ratio (OR), 31.93; 95% confidence interval (CI), 5.99-170.30; P < 0.001]. No major bleeding was recorded. Conclusions Underdose of LMWH is commonly used in cardiovascular inpatients, which was suboptimal according to guidelines. Using LMWH at a fixed, low dose for treatment purposes in patients without severe renal insufficiency was not associated with a higher risk of adverse vascular events in the current study, though larger studies with extended follow-ups are required to fully assess the long-term consequences of LMWH underdosing.