Hospital Pharmacy - October 2017 - 623

724799
research-article2017

HPXXXX10.1177/0018578717724799Hospital PharmacyGreen et al

Article

Safety and Efficacy of Enoxaparin
Compared With Unfractionated
Heparin for Venous Thromboembolism
Prophylaxis in Hemodialysis Patients

Hospital Pharmacy
2017, Vol. 52(9) 623-627
© The Author(s) 2017
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https://doi.org/10.1177/0018578717724799
DOI: 10.1177/0018578717724799
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Melissa S. Green1, Katie B. Tellor2, and Amanda R. Buckallew1

Abstract
Background: Enoxaparin, a low-molecular-weight heparin approved for prophylaxis in patients at risk for venous
thromboembolism (VTE), offers several advantages compared with unfractionated heparin (UFH). Enoxaparin is primarily
excreted through renal elimination and is currently not recommended in patients receiving hemodialysis (HD) due to potential
increased bleeding complications. To date, there are limited safety and efficacy data supporting the use of enoxaparin in
this patient population for VTE prophylaxis. Objective: The aim of this study was to compare the safety and efficacy
of enoxaparin with UFH for deep venous thromboembolism (DVT) prophylaxis in medically ill HD patients. Methods
and Results: This retrospective cohort study examined medically ill patients who received HD and were concomitantly
prescribed enoxaparin or UFH for at least 2 consecutive days for VTE prophylaxis. A total of 225 patients (150 received
UFH and 75 received enoxaparin) were evaluated in chronological order. The primary outcome was a composite of major,
clinically relevant nonmajor, and minor bleeding based on International Society on Thrombosis and Haemostasis bleeding
definitions. The secondary outcome was the occurrence of a confirmed thrombotic event. Baseline characteristics were
similar between the cohorts. One patient in each cohort had a documented bleed (UFH = 0.7%, enoxaparin = 1.3%, P > .05)
during the admission assessed; however, neither bleed was related to the prophylactic agent utilized. No patients developed
a VTE during the index hospitalization. Conclusions: This study demonstrates that enoxaparin may be as safe and effective
as UFH for VTE prophylaxis in medically ill patients receiving HD.
Keywords
heparin, enoxaparin, venous thromboembolism, prophylaxis, dialysis

Introduction
Enoxaparin is a low-molecular-weight heparin (LMWH)
approved by the US Food and Drug Administration in 1993
for prophylaxis in patients at risk for deep venous thrombosis
(DVT) and pulmonary embolism (PE).1 Compared with
unfractionated heparin (UFH), enoxaparin offers several
advantages when used for thromboprophylaxis, including
improved bioavailability, a longer half-life leading to less
frequent dosing, a more predictable dose-response, and less
thrombocytopenia.2-4 Eliminated primarily through the kidneys, enoxaparin exerts its anticoagulant effect by inactivating factor Xa.5 While a 30% dose reduction is recommended
for patients with renal dysfunction, enoxaparin is not
removed during dialysis and could therefore cause increased
bleeding complications.1,2,4,6
To date, the safety and efficacy of enoxaparin for venous
thromboembolism (VTE) prophylaxis has not been well
established for patients receiving hemodialysis (HD) due to a
lack of supporting data. In a retrospective study evaluating

enoxaparin for DVT treatment in morbidly obese patients,
renal dysfunction (defined as serum creatinine [SCr] >1.4
mg/dL) was not associated with increased bleeding. A multivariate analysis was performed analyzing independent risk
factors associated with bleeding. Female gender, warfarin
use, enoxaparin dose <0.9 mg/kg, and duration of enoxaparin
use >48 hours were independent risk factors for bleeding.7
Despite the fact that this study looked at DVT treatment dosing, renal dysfunction was not associated with increased
bleeding. Therefore, prophylactic enoxaparin dosing may
not be associated with increased bleeding risk in patients
with renal dysfunction.
1

Missouri Baptist Medical Center, St. Louis, MO, USA
St. Louis College of Pharmacy, MO, USA

Corresponding Author:
Melissa S. Green, Clinical Pharmacist, Missouri Baptist Medical Center,
3015 North Ballas Road, St. Louis, MO 63131, USA.
Email: melissa.green@ssmhealth.com

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