Advertisement

International Journal of Clinical Pharmacy

, Volume 33, Issue 6, pp 934–941 | Cite as

The appropriateness of enoxaparin use in Lebanese hospitals: a quality evaluation study

  • A. A. ZeitounEmail author
  • J. G. Nassif
  • M. M. Zeineddine
Research Article

Abstract

Background Although, guidelines for the appropriate use of enoxaparin are published, yet the extent of their implementation in clinical practice is still questionable. Furthermore, the optimal dosing of enoxaparin in special populations such as renal insufficiency and obesity remains controversial. In the Middle East, there are insufficient data on the appropriateness of enoxaparin use in different indications. Objective (1) To assess the appropriateness of enoxaparin dosing and duration per indication in compliance with the recommended guidelines and their impact on safety and efficacy outcomes in Lebanese health care centers. (2) To evaluate the influence of the hospital type (teaching vs. non-teaching) on the extent of compliance with established guidelines. Setting Seventeen health care centers in Lebanon, including teaching and non-teaching hospitals. Methods An observational, cross-sectional, multicenter study was conducted in 17 Lebanese hospitals. Data on demographics, indication, dosing regimen and clinical outcomes were collected. The appropriateness of dosing practices was determined as per the ACCP guidelines and the FDA dosing recommendations. Main outcome measure The appropriateness of enoxaparin dosing was compared across different hospital type and among special populations including severe renal insufficiency and very obese patients. Results Of the 463 patients who participated in the study, 40% received improper enoxaparin dosing, which was mostly observed in the VTE prophylaxis group (41.6%, P < 0.001). When comparing the overall dosing practices in Lebanese hospitals, there was no statistically significant difference in the correctness of enoxaparin dosing between teaching and non-teaching hospitals (61.6% vs. 58.2%, P = 0.449), respectively. Only 11.5% of renally impaired patients and 59.4% of obese patients received correct doses. Conclusion This study highlighted the improper practice and thus the need of implementation of clinical practice guidelines for the dosing of enoxaparin, in Lebanese hospitals.

Keywords

Appropriateness Dosing Enoxaparin Hospital pharmacy Lebanon Low molecular weight heparin Obese Renal impairment 

Notes

Funding

No funding was received.

Conflicts of interest

None.

References

  1. 1.
    Cohen M, Demers C, Gurfinkel E, Turpie A, Fromell G, Goodman S, et al. A comparison of low molecular weight heparin with unfractionated heparin for unstable coronary artery disease. N Engl J Med. 1997;337(7):447–52.PubMedCrossRefGoogle Scholar
  2. 2.
    Blazing M, de Lemos J, White H, Fox K, Verheugt F, Ardissino D, et al. Safety and efficacy of enoxaparin versus unfractionated heparin in patients with non-ST-segment elevation acute coronary syndromes who receive tirofiban and aspirin. A randomized controlled trial. JAMA. 2004;292(10):55–64.PubMedCrossRefGoogle Scholar
  3. 3.
    Ferguson J, Califf R, Antman E, Cohen M, Grines C, Goodman S, et al. Enoxaparin versus unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy. JAMA. 2004;292(1):45–54.PubMedCrossRefGoogle Scholar
  4. 4.
    Quinlan DJ, McQuillan A, Eikelboom JW. Low-molecular-weight-heparin compared with intravenous heparin for treatment of pulmonary embolism. Ann Intern Med. 2004;140(3):175–83.PubMedGoogle Scholar
  5. 5.
    Merli G, Spiro T, Olsson C, Abildgaard U, Davidson B, Eldor A, et al. Subcutaneous enoxaparin once or twice daily compared with intravenous heparin for the treatment of venous thromboembolic disease. Ann Intern Med. 2001;134(3):191–202.PubMedGoogle Scholar
  6. 6.
    Boneu B. Low molecular weight heparins: are they superior to unfractionated heparins to prevent and to treat deep vein thrombosis? Thromb Res. 2000;100(2):V113–20.PubMedCrossRefGoogle Scholar
  7. 7.
    Hirsh J, Warkentin T, Raschke R, Granger C, Ohman E, Dalen J. Heparin and low-molecular-weight heparin. Chest. 1999;115(6):489–510.Google Scholar
  8. 8.
    Weitz JI. Low-molecular-weight heparins. N Engl J Med. 1997;337(21):688–98.PubMedGoogle Scholar
  9. 9.
    Hirsh J, Bauer K, Donati M, Gould M, Samama M, Weitz J. Parenteral anticoagulants: American college of chest physicians evidence-based clinical practice guidelines (8th ed). Chest. 2008;133(6):141S–59S.PubMedCrossRefGoogle Scholar
  10. 10.
    Geerts W, Bergqvist D, Pineo G, Heit J, Samama C, Lassen M, et al. Prevention of venous thromboembolism: American college of chest physicians evidence-based clinical practice guidelines (8th ed). Chest. 2008;133(6):381S–453S.PubMedCrossRefGoogle Scholar
  11. 11.
    Kearon C, Kahn S, Agnelli G, Goldhaber S, Raskob G, Comerota A. Antithrombotic therapy for venous thromboembolic disease: American college of chest physicians evidence-based clinical practice guidelines (8th ed). Chest. 2008;133(6):454S–545S.PubMedCrossRefGoogle Scholar
  12. 12.
    Harrington R, Becker R, Cannon C, Gutterman D, Lincoff A, Popma J, et al. Antithrombotic therapy for non ST segment elevation acute coronary syndromes: American college of chest physicians evidence-based clinical practice guidelines (8th ed). Chest. 2008;133(6):670S–707S.PubMedCrossRefGoogle Scholar
  13. 13.
    Sanofi-Aventis US LLC. Lovenox® (enoxaparin sodium injection) prescribing information. Bridgewater: Sanofi-Aventis US LLC; 2008.Google Scholar
  14. 14.
    Chopard P, Dörffler-Melly J, Hess U, Wuillemin W, Hayoz D, Gallino A, et al. Venous thromboembolism prophylaxis in acutely ill medical patients: definite need for improvement. J Intern Med. 2005;257(4):352–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Becker R, Spencer F, Gibson M, Rush J, Sanderink G, Murphy S, et al. Influence of patient characteristics and renal function on factor Xa inhibition pharmacokinetics and pharmacodynamics after enoxaparin administration in non-ST elevation acute coronary syndromes. Am Heart J. 2002;143(5):753–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Mahe I, Gouin-Thibalt I, Drouet L, Simoneau G, Di Castillo H, Siguret V, et al. Elderly medical patients created with prophylactic dosages of enoxaparin: influence of renal function on anti-Xa activity level. Drugs Aging. 2007;24:63–71.PubMedCrossRefGoogle Scholar
  17. 17.
    Lim W, Dentali F, Eikelboom JW, Crowther MA. Meta-analysis: low-molecular-weight heparin and bleeding in patients with severe renal insufficiency. Ann Intern Med. 2006;144(9):673–84.PubMedGoogle Scholar
  18. 18.
    Montalescot G, Collet J, Tanguy M, Ankri A, Payot L, Dumaine R, et al. Anti-Xa activity relates to survival and efficacy in unselected acute coronary syndrome patients treated with enoxaparin. Circulation. 2004;110(4):392–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Turpie A. Thrombosis prophylaxis in the acutely ill medical patient: insights from the prophylaxis in medical patients with enoxaparin (medenox) Trial. Am J Cardiol. 2000;86:48–52.CrossRefGoogle Scholar
  20. 20.
    Cheymol G. Effects of obesity on pharmacokinetics implications for drug therapy. Clin Pharmacokinet. 2000;39(3):215–31.PubMedCrossRefGoogle Scholar
  21. 21.
    Sanderink G, Le Liboux A, Jariwala N, Harding N, Ozoux M, Shukla U, et al. The pharmacokinetics and pharmacodynamics of enoxaparin in obese volunteers. Clin Pharmacol Ther. 2002;72(3):308–18.PubMedCrossRefGoogle Scholar
  22. 22.
    Bazinet A, Almanric K, Brunet C, Turcotte I, Martineau J, Caron S, et al. Dosage of enoxaparin among obese and renal impairment patients. Thromb Res. 2005;116(1):41–50.PubMedCrossRefGoogle Scholar
  23. 23.
    Wilson S, Wilbur K, Burton E, Anderson D. Effect of patient weight on the anticoagulant response to adjusted therapeutic dosage of low-molecular-weight heparin for the treatment of venous thromboembolism. Haemostasis. 2001;31(1):42–8.PubMedGoogle Scholar
  24. 24.
    Duplaga BA, Rivers CW, Nutescu E. Dosing and monitoring of low-molecular weight heparins in special populations. Pharmacotherapy. 2001;21(2):218–34.PubMedCrossRefGoogle Scholar
  25. 25.
    Kucher N, Leizorovicz A, Vaitkus P, Cohen A, Turpie A, Olsson C, et al. Efficacy and safety of fixed low-dose dalteparin in preventing venous thromboembolism among obese or elderly hospitalized patients: a subgroup analysis of the PREVENT trial. Arch Intern Med. 2005;165(3):341–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Rondina M, Wheeler M, Rodgers G, Draper L, Pendleton R. Weight-based dosing of enoxaparin for VTE prophylaxis in morbidly obese, medically-ill patients. Thromb Res. 2010;125(3):220–3.PubMedCrossRefGoogle Scholar
  27. 27.
    Vats V, Nutescu E, Theobald J, Wojtynek J, Schumock G. Survey of hospitals for guidelines, policies, and protocols for anticoagulants. Am J Health Syst Pharm. 2007;64(11):1203–8.PubMedCrossRefGoogle Scholar
  28. 28.
    World Health Organization. Report of a WHO consultation on obesity: preventing and managing the global epidemic. Geneva: World Health Organization; 1998.Google Scholar
  29. 29.
    Cockcroft DW, Gault MN. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31–41.PubMedCrossRefGoogle Scholar
  30. 30.
    Macie C, Forbes L, Foster G, Douketis J. 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.PubMedCrossRefGoogle Scholar
  31. 31.
    Al-Sallami H, Jordan S, Ferguson R, Medlicott N, Schollum J, Duffull S. Current enoxaparin dosing guidelines have dubious credibility. N Z Med J. 2010;123(1313):62–7.PubMedGoogle Scholar
  32. 32.
    Taher AT, Aoun J, Salameh P. The AVAIL ME study: a multinational survey of VTE risk and prophylaxis. J Thromb Thrombolysis. 2011;31(1):47–56.PubMedCrossRefGoogle Scholar
  33. 33.
    Rothberg M, Lahti M, Pekow P, Lindenauer P. Venous thromboembolism prophylaxis among medical patients at US hospitals. J Gen Intern Med. 2010;25(6):489–94.PubMedCrossRefGoogle Scholar
  34. 34.
    Masroujeh R, Shamseddeen W, Isma’eel H, Otrock Z, Khalil I, Taher A, et al. Underutilization of venous thromboembolism prophylaxis in medical patients in a tertiary care center. J Thromb Thrombolysis. 2008;26(2):138–41.PubMedCrossRefGoogle Scholar
  35. 35.
    Tincani E, Crowther M, Turrini F, Prisco D. Prevention and treatment of venous thromboembolism in the elderly population. Clin Interv Aging. 2007;2(2):237–46.PubMedGoogle Scholar
  36. 36.
    Spicer K, Gibson P, Bloe C, Cross S, Leslie S, et al. Weight assessment in cardiac patients: implications for prescription of low molecular weight heparin. Postgrad Med J. 2009;85(1001):124–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Scholten D, Hoedema R, Scholten S. A comparison of two different prophylactic dose regimens of low molecular weight heparin in bariatric surgery. Obes Surg. 2002;12(1):19–24.PubMedCrossRefGoogle Scholar
  38. 38.
    Ellis M, Hadari R, Tchuvrero N, Shapira S, Kovlenko I, Kozmiakova M, et al. Hemorrhagic complications in patients treated with anticoagulant doses of low molecular weight heparin (enoxaparin) in routine hospital practice. Clin Appl Thromb Hemost. 2006;12(2):199–204.PubMedCrossRefGoogle Scholar
  39. 39.
    Nieto J, Solano R, Ruiz-Ribo M, Ruiz-Gimenez N, Prandoni P, Kearon C, et al. Fatal bleeding in patients receiving anticoagulant therapy for venous thromboembolism: findings from the RIETE registry. Thromb Haemostasis. 2010;8(6):1216–22.CrossRefGoogle Scholar
  40. 40.
    The Thrombolysis in Myocardial Infarction (TIMI) 11A Trial Investigators. Dose-ranging trial of enoxaparin for unstable angina: results of TIMT 11A. J Am Coll Cardiol. 1997;29(7):1474–82.CrossRefGoogle Scholar
  41. 41.
    Gouin-Thibalt I, Pautas E, Siguret V. Safety profiles of different low molecular weight heparins used at therapeutic dose. Drug Saf. 2005;28(4):333–49.CrossRefGoogle Scholar
  42. 42.
    Al-Sallami H, Barras M, Green B, Duffull S. Routine plasma anti-Xa monitoring is required for low-molecular-weight heparins. Clin Pharmacokinet. 2010;49(9):567–71.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2011

Authors and Affiliations

  • A. A. Zeitoun
    • 1
    Email author
  • J. G. Nassif
    • 2
  • M. M. Zeineddine
    • 3
  1. 1.School of Pharmacy, Pharmacy Practice DepartmentLebanese American UniversityByblosLebanon
  2. 2.School of Pharmacy, Pharmacy Practice DepartmentLebanese American UniversityByblosLebanon
  3. 3.School of PharmacyLebanese American UniversityByblosLebanon

Personalised recommendations