An analysis of in-hospital enoxaparin prescription and bleeding in the predominately middle-, and oldest-old population: insights from a secondary care hospital
Main Article Content
Keywords
Enoxaparin, Thromboembolism, Hemorrhage, Elderly, Secondary care
Abstract
Background: Enoxaparin is one of the widely used injectable anticoagulants requiring dose adjustment based on body weight and renal function. Unadjusted or inappropriately adjusted doses can lead to thromboembolic or bleeding events, particularly in patients with advanced age. Objectives: This retrospective chart review study primarily aimed to evaluate enoxaparin use, along with exploring factors associated with inappropriate use and bleeding in the elderly population. Methods: Baseline characteristics, along with bleeding and thrombotic events, of the patients receiving enoxaparin in the fiscal year 2018-2019 at a secondary care hospital were extracted from the electronic medical record. Prescribed enoxaparin regimens were evaluated against the recommended dose in the package insert, pertinent guidelines, and hospital guidance. Univariate and multivariate analyses were performed to explore factors associated with inappropriate use and bleeding. Results: Two hundred and fourteen patients were included. The majority (66.8%) were female, and 39.7% were 80 years or older, with an average age of 74.4 years and a body mass index (BMI) of 24.0 kg/m2. Most patients (82.7%) had a creatinine clearance ≥30 ml/min. Seventy-six initiations (35.5%) were inappropriate, and 83 problems were found. Underdosing was the most common problem (39.8%), followed by undocumented body weight (22.9%), and inconsistent prophylactic dose per hospital guidance (20.5%). BMI ≥25kg/m2 (odds ratio [OR] 2.04 [95% confidence interval [CI] 1.04:3.98]; p=0.04) was the only factor associated with inappropriate use. There were 48 bleedings (22.4%), 21 minor (9.8%), and 27 major (12.6%). Hemoglobin (Hb) <10g/dL was associated with bleedings across all indications (OR 4.25 [95%CI 2.03:8.91]; p<0.01). Conclusions: In the predominately middle-, and oldest-old population, inappropriate use of enoxaparin was common. Those with BMI ≥25kg/m2 and Hb<10g/dL were at increased risk of underdosing and bleedings, respectively; these patients should be closely monitored.
References
2. United Nations, Economic and Social Commission for Asia and the Pacific (ESCAP)(2022). Asia-Pacific Report on Population Ageing 2022: Trends, policies and good practices regarding older persons and population ageing (ST/ESCAP/3041). [Internet].
2022 [cited 2023 Jan 8]. Available from: https://www.unescap.org/kp/2022/asia-pacific-report-population-ageing-2022-trends-policies-and-good-practices-regarding.
3. Bloom G. Service Delivery Transformation for UHC in Asia and the Pacific. Health Syst Reform. 2019;5(1):7-17. https://doi.or g/10.1080/23288604.2018.1541498
4. WHO 2020. Global Health Estimates 2019: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2019. Geneva.[Internet].2020 [cited 2023 Jan 8]. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death
5. Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events. JAMA. 2006;296(15):1858-66. https://doi.org/10.1001/jama.296.15.1858
6. Choi E, Kim S, Suh HS. Exploring the prevalence and characteristics of adverse drug events among older adults in South Korea using a national health insurance database. Front Pharmacol. 2022;13:1047387. https://doi.org/10.3389/fphar.2022.1047387
7. Enoxaparin sodium. United States prescribing information. Revised April 2022. Available at: https://products.sanofi.us/ lovenox/lovenox.pdf.(Accessed on December 28, 2022).
8. Fareed J, Hoppensteadt D, Walenga J, et al. Pharmacodynamic and pharmacokinetic properties of enoxaparin :implications for clinical practice. Clin Pharmacokinet. 2003;42(12):1043-57. https://doi.org/10.2165/00003088-200342120-00003
9. Lexicomp. (n.d.). Enoxaparin: Drug information. UpToDate. 2022 [cited 2022 Dec 28]. Available from: https://www.uptodate.com/contents/enoxaparin-including-biosimilars-available-in-canada-drug-information?search=enoxaparin&source=panelsearch-result&selectedTitle=1~124&usage-type=panel&kp-tab=drug-general&display-rank=1
10. Nutescu EA, Spinler SA, Wittkowsky A, et al. Low-molecular-weight heparins in renal impairment and obesity: available evidence and clinical practice recommendations across medical and surgical settings. Ann Pharmacother. 2009;43(6):1064-83.https://doi.org/10.1345/aph.1L194
11. LaPointe NM, Chen AY, Alexander KP, et al. Enoxaparin dosing and associated risk of in-hospital bleeding and death in patients with non ST-segment elevation acute coronary syndromes. Arch Intern Med. 2007;167(14):1539-44. https://doi.org/10.1001/archinte.167.14.1539
12. Levin A, Ben-Artzi M, Beckerman P, et al. Factors associated with bleeding in elderly hospitalized patients treated with enoxaparin sodium : a prospective, open-label, observational study. Drugs Aging. 2009;26(1):77-85. https://doi.org/10.2165/0002512-200926010-00006
13. Macie C, Forbes L, Foster GA, et al. Dosing practices and risk factors for bleeding in patients receiving enoxaparin for the treatment of an acute coronary syndrome. Chest. 2004;125(5):1616-21. https://doi.org/10.1378/chest.125.5.1616
14. Mismetti P, Quenet S, Levine M, et al. Enoxaparin in the treatment of deep vein thrombosis with or without pulmonary embolism: an individual patient data meta-analysis. Chest. 2005;128(4):2203-10. https://doi.org/10.1378/chest.128.4.2203
15. Petersen JL, Mahaffey KW, Hasselblad V, et al. Efficacy and bleeding complications among patients randomized to enoxaparin or unfractionated heparin for antithrombin therapy in non-ST-Segment elevation acute coronary syndromes: a systematic overview. JAMA. 2004;292(1):89-96. https://doi.org/10.1001/jama.292.1.89
16. Schulman S, Kearon C, Subcommittee on Control of Anticoagulation of the S, Standardization Committee of the International Society on T, Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in nonsurgical patients. J Thromb Haemost. 2005;3(4):692-4. https://doi.org/10.1111/j.1538-7836.2005.01204.x
17. Sofjan AK, Iuppa JA, Bain KB, et al. Evaluation of Enoxaparin Dosing as a Risk Factor for Bleeding in Lung Transplant Recipients.Ann Pharmacother. 2016;50(10):824-31. https://doi.org/10.1177/1060028016656434
18. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest.2016;149(2):315-52. https://doi.org/10.1016/j.chest.2015.11.026
19. Grant SW, Hickey GL, Head SJ. Statistical primer: multivariable regression considerations and pitfalls. Eur J Cardiothorac Surg. 2019;55(2):179-85. https://doi.org/10.1093/ejcts/ezy403
20. World Health Organization. Regional Office for the Western Pacific. The Asia-Pacific perspective : redefining obesity and its treatment. Sydney : Health Communications Australia. [Internet]. 2000 [cited 2022 Dec 28]. Available from: https://apps.who.int/iris/handle/10665/206936.
21. Tran VN, Varfolomeev I, Hill G. Prophylactic Enoxaparin Dosing in Obese Orthopedic Patients: A Literature Search. Hosp Pharm. 2020;55(6):366-72. https://doi.org/10.1177/0018578719848732
22. Garcia DA, Baglin TP, Weitz JI, et al. Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e24S-e43S.https://doi.org/10.1378/chest.11-2291
23. Rondina MT, Wheeler M, Rodgers GM, et al. Weight-based dosing of enoxaparin for VTE prophylaxis in morbidly obese, medically-Ill patients. Thromb Res. 2010;125(3):220-3. https://doi.org/10.1016/j.thromres.2009.02.003
24. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest.2012;141(2 Suppl):e278S-e325S. https://doi.org/10.1378/chest.11-2404
25. Kahn SR, Lim W, Dunn AS, et al. 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. 2012;141(2 Suppl):e195S-e226S. https://doi.org/10.1378/chest.11-2296
26. Gupta VK, Gupta KK, Sanghera RS, et al. A Basic Intervention to Improve Compliance With Thromboprophylaxis in Patients With Neck of Femur Fracture. Ochsner J. 2021;21(2):173-6. https://doi.org/10.31486/toj.20.0093
27. Bruno R, Baille P, Retout S, et al. Population pharmacokinetics and pharmacodynamics of enoxaparin in unstable angina and non-ST-segment elevation myocardial infarction. Br J Clin Pharmacol. 2003;56(4):407-14. https://doi.org/10.1046/j.1365-2125.2003.01904.x
28. Turpie AG, Bauer KA, Eriksson BI, et al. Fondaparinux vs enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a meta-analysis of 4 randomized double-blind studies. Arch Intern Med. 2002;162(16):1833-40. https://doi.org/10.1001/archinte.162.16.1833
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