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Hospital Pharmacy 52(9)
Discussion
Table 2. Outcomes.
Outcome, n (%)
Leg Doppler ultrasounds
confirming VTE
Chest CT confirming VTE
VQ scan confirming VTE
Elevated D-dimer
Documented bleed
Documented bleed
related to prophylaxis
Major bleed
CRNM
Minor bleed
UFH
(n = 150)
Enoxaparin
(n = 75)
P value
0 (0)
0 (0)
NA
0 (0)
0 (0)
0 (0)
1 (0.7)
0 (0)
0 (0)
0 (0)
0 (0)
1 (1.3)
0 (0)
NA
NA
NA
1
NA
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
NA
NA
NA
Note. CRNM = clinically relevant non-major; CT = computed tomography;
NA = not applicable; UFH = unfractionated heparin; VTE = venous
thromboembolism.
study period. Heparin boluses associated with HD treatment
were provided to 86.7% of patients in each cohort. Other
concomitant antithrombotics utilized in the study population
included prasugrel, clopidogrel, and alteplase. The alteplase
doses included were those administered to maintain central
venous catheter clearance; all other doses of alteplase were
excluded. Neither group had a statistically significant difference in use of these medications.
A PADUA score of ≥4 points indicates a need for VTE
prophylaxis.10 Based on the mean PADUA score, enoxaparin
patients did not require prophylaxis for the hospital admissions assessed. The UFH cohort had a mean PADUA score of
4.2 and the enoxaparin cohort had a mean PADUA score of
3.5 (P < .05). There were statistically more patients in the
UFH cohort who had reduced mobility when compared with
the enoxaparin cohort, 144 patients (96%) and 59 (78.7%),
respectively (P < .05). The other components of the PADUA
score were not statistically different.
One patient in each study cohort had a documented bleed
during the admissions assessed. However, neither bleed was
related to the prophylaxis agent utilized. The patient in the
UFH cohort experienced acute blood loss anemia secondary
to a gastrointestinal bleed. The patient in the enoxaparin
cohort presented with vaginal bleeding and acute blood loss
anemia. Both patients were provided 2 units of PRBCs; however, neither bleeding event was attributed to the prophylactic agent received during their hospitalization because the
patients were stabilized before a prophylaxis agent was initiated. An Hgb drop ≥2 g/dL occurred in 15 patients (10%) in
the UFH cohort and in 5 patients (6.7%) in the enoxaparin
cohort (P = .408). In the UFH group, 4 patients (2.7%)
required ≥2 units of PRBCs while on VTE prophylaxis,
whereas 1 patient (1.3%) in the enoxaparin group required
≥2 units of PRBCs (P = .667). All patients received PRBCs
due to anemia of CKD. No patients developed a VTE during
the study period.
This study illustrates that enoxaparin 30 mg daily may be as
safe and effective as UFH 5000 units every 8 hours for VTE
prophylaxis in medically ill patients receiving HD. Although
only 1 patient in each cohort had a bleeding event, no patients
in either cohort experienced a bleeding event directly attributed to the prophylactic regimen administered during their
hospitalization.
There are several limitations within this study. Patients
were only included from a single-center, community hospital, and the sample size was limited. The small sample size
might not have been adequately powered to detect a difference in bleeding events between cohorts. In addition, the retrospective nature of this study limited data extraction only to
information that was documented in the patient's electronic
health record. Physicians were also able to make decisions
about the patient's care during the study period, so outcomes
from this study could be affected by their decisions. If any
decisions were undocumented, this could lead to misrepresentation of the study's results. Another limitation includes
the differing hospitalization durations between treatment
groups. Enoxaparin is renally eliminated and could accumulate over an extended period of time in patients receiving
HD. As the enoxaparin cohort had a shorter LOS, there is a
chance that the incidence of bleeding is underrepresented. In
addition, the patients in the enoxaparin cohort had a lower
thromboembolic risk. Based on the average PADUA score of
3.5, patients who received enoxaparin may not be at risk for
developing a VTE. 10
Previous studies have demonstrated similar results. A retrospective comparative effectiveness analysis by Chan and
colleagues analyzed chronic HD and PD patients initiated on
subcutaneous enoxaparin or UFH for the prevention of DVT
and PE.11 The primary end point was bleeding that resulted
in hospitalization or death within 120 days of enoxaparin
or heparin treatment initiation. Low doses (up to 60 mg of
enoxaparin) were injected daily. Enoxaparin and UFH were
equivalent in terms of bleeding risk (risk ratio [RR] = 0.98;
95% confidence interval [CI] = 0.78-1.23; P for equivalence
= .02), and enoxaparin was noninferior in terms of thrombosis (RR = 0.77; 95% CI = 0.49-1.22; P = .04 for noninferiority).11 Higher than standard doses recommended for patients
with renal impairment were utilized in dialysis patients without increased bleeding risks.
The results of the present study, as well as the study by
Chan and colleagues, suggest enoxaparin and UFH may be
similar in terms of bleeding and thrombotic risk. Chan and
colleagues utilized a dose of enoxaparin that was greater than
the standard recommended dose for prophylaxis in patients
with renal dysfunction. Yet, even when patients were provided a higher dose, there was an equivalent bleeding risk
between the enoxaparin and UFH treatment groups. The
current study utilized standard doses of enoxaparin based
on package insert recommendations for patients with a
Table of Contents for the Digital Edition of Hospital Pharmacy - October 2017
Pharmacists and Medical Missions
Current FDA-Related Drug Information
Summaries of Safety Labeling Changes Approved By FDA- Boxed Warnings Highlights April-June 2017
Pharmaceutical Pipeline Update
Cholesterol Ester Transfer Protein Inhibitor Review
Formulary Drug Review
Ocrelizumab
Patient Outcomes Associated With Phenobarbital Use With or Without Benzodiazepines for Alcohol Withdrawal Syndrome: A Systematic Review
Development of a Pharmacy Technician–Driven Program to Improve Vaccination Rates at an Academic Medical Center
Safety and Efficacy of Enoxaparin Compared With Unfractionated Heparin for Venous Thromboembolism Prophylaxis in Hemodialysis Patients
Multilayer Model of Pharmacy Participation in the Antimicrobial Stewardship Program at a Large Academic Medical Center
Impact of Inpatient Automatic Therapeutic Substitutions on Postdischarge Medication Prescribing
Impact of Respiratory Viral Panel Polymerase Chain Reaction Assay Turnaround Time on Length of Stay and Antibiotic Use in Patients With Respiratory Viral Illnesses
Administration of Injectable Vitamin K Orally
Hospital Pharmacy - October 2017 - 577
Hospital Pharmacy - October 2017 - 578
Hospital Pharmacy - October 2017 - 579
Hospital Pharmacy - October 2017 - 580
Hospital Pharmacy - October 2017 - 581
Hospital Pharmacy - October 2017 - 582
Hospital Pharmacy - October 2017 - 583
Hospital Pharmacy - October 2017 - 584
Hospital Pharmacy - October 2017 - 585
Hospital Pharmacy - October 2017 - 586
Hospital Pharmacy - October 2017 - 587
Hospital Pharmacy - October 2017 - 588
Hospital Pharmacy - October 2017 - Pharmacists and Medical Missions
Hospital Pharmacy - October 2017 - Current FDA-Related Drug Information
Hospital Pharmacy - October 2017 - Summaries of Safety Labeling Changes Approved By FDA- Boxed Warnings Highlights April-June 2017
Hospital Pharmacy - October 2017 - 592
Hospital Pharmacy - October 2017 - Pharmaceutical Pipeline Update
Hospital Pharmacy - October 2017 - Cholesterol Ester Transfer Protein Inhibitor Review
Hospital Pharmacy - October 2017 - 595
Hospital Pharmacy - October 2017 - Formulary Drug Review
Hospital Pharmacy - October 2017 - Ocrelizumab
Hospital Pharmacy - October 2017 - 598
Hospital Pharmacy - October 2017 - 599
Hospital Pharmacy - October 2017 - 600
Hospital Pharmacy - October 2017 - 601
Hospital Pharmacy - October 2017 - 602
Hospital Pharmacy - October 2017 - 603
Hospital Pharmacy - October 2017 - 604
Hospital Pharmacy - October 2017 - Patient Outcomes Associated With Phenobarbital Use With or Without Benzodiazepines for Alcohol Withdrawal Syndrome: A Systematic Review
Hospital Pharmacy - October 2017 - 606
Hospital Pharmacy - October 2017 - 607
Hospital Pharmacy - October 2017 - 608
Hospital Pharmacy - October 2017 - 609
Hospital Pharmacy - October 2017 - 610
Hospital Pharmacy - October 2017 - 611
Hospital Pharmacy - October 2017 - 612
Hospital Pharmacy - October 2017 - 613
Hospital Pharmacy - October 2017 - 614
Hospital Pharmacy - October 2017 - Development of a Pharmacy Technician–Driven Program to Improve Vaccination Rates at an Academic Medical Center
Hospital Pharmacy - October 2017 - 616
Hospital Pharmacy - October 2017 - 617
Hospital Pharmacy - October 2017 - 618
Hospital Pharmacy - October 2017 - 619
Hospital Pharmacy - October 2017 - 620
Hospital Pharmacy - October 2017 - Safety and Efficacy of Enoxaparin Compared With Unfractionated Heparin for Venous Thromboembolism Prophylaxis in Hemodialysis Patients
Hospital Pharmacy - October 2017 - 622
Hospital Pharmacy - October 2017 - 623
Hospital Pharmacy - October 2017 - 624
Hospital Pharmacy - October 2017 - 625
Hospital Pharmacy - October 2017 - Multilayer Model of Pharmacy Participation in the Antimicrobial Stewardship Program at a Large Academic Medical Center
Hospital Pharmacy - October 2017 - 627
Hospital Pharmacy - October 2017 - 628
Hospital Pharmacy - October 2017 - 629
Hospital Pharmacy - October 2017 - 630
Hospital Pharmacy - October 2017 - 631
Hospital Pharmacy - October 2017 - 632
Hospital Pharmacy - October 2017 - Impact of Inpatient Automatic Therapeutic Substitutions on Postdischarge Medication Prescribing
Hospital Pharmacy - October 2017 - 634
Hospital Pharmacy - October 2017 - 635
Hospital Pharmacy - October 2017 - 636
Hospital Pharmacy - October 2017 - 637
Hospital Pharmacy - October 2017 - Impact of Respiratory Viral Panel Polymerase Chain Reaction Assay Turnaround Time on Length of Stay and Antibiotic Use in Patients With Respiratory Viral Illnesses
Hospital Pharmacy - October 2017 - 639
Hospital Pharmacy - October 2017 - 640
Hospital Pharmacy - October 2017 - 641
Hospital Pharmacy - October 2017 - 642
Hospital Pharmacy - October 2017 - Administration of Injectable Vitamin K Orally
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Hospital Pharmacy - October 2017 - 645
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Hospital Pharmacy - October 2017 - 647
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