Thread by @AnnKumfer, #MedTwitter A patient is admitted to the hospital with sepsis. You are [...]

Ann Marie Kumfer

AnnKumfer

#MedTwitter A patient is admitted to the hospital with sepsis. You are ordering DVT prophylaxis. CrCl is 60 ml/min and BMI 43. What do you start as prophylaxis?

2/In this study of hospitalized patients with BMI >40, use of standard LMWH dosing (40mg daily) rarely resulted in target anti-Xa level.
https://pubmed.ncbi.nlm.nih.gov/22565589/

Enoxaparin ppx superior to heparin in most outcomes per 2014 Cochrane review including risk of DVT (OR 0.77) and major bleeding (OR 0.43) although no difference in mortality.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6491079/

4/ Higher absolute risk of HIT with UFH (2.6%) than with LMWH (0.2%). https://pubmed.ncbi.nlm.nih.gov/15985543/

Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin...

Heparin-induced thrombocytopenia (HIT) is an uncommon but potentially devastating complication of anticoagulation with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Our...

https://pubmed.ncbi.nlm.nih.gov/15985543/

5/This recent study in pts with BMI>40 showed that WB statically similar compared to BID dosing of enoxaparin. No significant bleeding events noted.
https://pubmed.ncbi.nlm.nih.gov/33400099/

Conclusions:
1. LMWH (enoxaparin) superior to UFH (heparin) in outcomes and lower risk of HIT.
2. In pts with BMI >40, standard enoxaparin dosing (40mg daily) rarely led to target anti-Xa levels.
3. Use of enoxaparin 40mg BID or weight based dosing similar outcomes.

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