Obesity Surgery

, Volume 19, Issue 8, pp 1186–1189 | Cite as

Treatment of Pulmonary Embolism in an Extremely Obese Patient

  • Jeroen Diepstraten
  • Simone van Kralingen
  • Repke J. Snijder
  • Christian M. Hackeng
  • Bert van Ramshorst
  • Catherijne A. J. Knibbe
Case Report


Low-molecular-weight heparins are effective as initial therapy for pulmonary embolism (PE) in a weight-based dosing regimen up to known body weights of 160 kg. The present case reports an extremely obese man of 252 kg (body mass index (BMI) 74 kg/m2) with PE who was treated with tinzaparin, dosed on a body weight of 160 kg. Morbid obesity defined as a BMI higher than 40 kg/m2 is becoming more common in general practice, but there are no evidence-based drug dosing strategies for these patients. This case demonstrates the successful use of a maximum dose of 28,000 anti-Xa international units of tinzaparin for an extremely obese patient with proven PE, instead of the accepted doses of 175 IU/kg, as bridge therapy to a coumarin.


Anti-Xa activity Low-molecular-weight heparin Morbid obesity Pulmonary embolism Tinzaparin 


  1. 1.
    Eikelboom JW, Karthikeyan G, Fagel N, et al. American Association of Orthopedic Surgeons and American College Of Chest Physicians guidelines for venous thromboembolism prevention in hip and knee arthroplasty differ: what are the implications for clinicians and patients? Chest. 2009;135(2):513–20.CrossRefGoogle Scholar
  2. 2.
    Hainer JW, Barrett JS, Assaid CA, et al. Dosing in heavy-weight/obese patients with the LMWH, tinzaparin: a pharmacodynamic study. Thromb Haemost. 2002;87(5):817–23.CrossRefGoogle Scholar
  3. 3.
    Barrett JS, Gibiansky E, Hull RD, et al. Population pharmacodynamics in patients receiving tinzaparin for the prevention and treatment of deep vein thrombosis. Int J Clin Pharmacol Ther. 2001;39(10):431–46.PubMedGoogle Scholar
  4. 4.
    Hull RD, Raskob GE, Pineo GF, et al. Subcutaneous low-molecular-weight heparin compared with continuous intravenous heparin in the treatment of proximal-vein thrombosis. N Engl J Med. 1992;326(15):975–82.CrossRefGoogle Scholar
  5. 5.
    Montalescot G, Collet JP, Tanguy ML, 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.CrossRefGoogle Scholar
  6. 6.
    Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):188S–203S.CrossRefGoogle Scholar
  7. 7.
    Kopelman PG. Obesity as a medical problem. Nature. 2000;404(6778):635–43.CrossRefGoogle Scholar
  8. 8.
    World Health Organisation. Obesity: preventing and managing the global epidemic. Geneva: World Health Organisation; 1997.Google Scholar
  9. 9.
    Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA. 2006;295(13):1549–55.CrossRefGoogle Scholar
  10. 10.
    Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979–1998: an analysis using multiple-cause mortality data. Arch Intern Med. 2003;163(14):1711–7.CrossRefGoogle Scholar
  11. 11.
    Goldhaber SZ, Grodstein F, Stampfer MJ, et al. A prospective study of risk factors for pulmonary embolism in women. JAMA. 1997;277(8):642–5.CrossRefGoogle Scholar
  12. 12.
    Wells PS, Anderson DR, Rodger MA, et al. A randomized trial comparing 2 low-molecular-weight heparins for the outpatient treatment of deep vein thrombosis and pulmonary embolism. Arch Intern Med. 2005;165(7):733–8.CrossRefGoogle Scholar
  13. 13.
    Hull RD. Treatment of pulmonary embolism: the use of low-molecular-weight heparin in the inpatient and outpatient settings. Thromb Haemost. 2008;99(3):502–10.CrossRefGoogle Scholar
  14. 14.
    Neely JL, Carlson SS, Lenhart SE. Tinzaparin sodium: a low-molecular-weight heparin. Am J Health Syst Pharm. 2002;59(15):1426–36.PubMedGoogle Scholar
  15. 15.
    Wilson SJ, Wilbur K, Burton E, et al. 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
  16. 16.
    Davidson BL, Buller HR, Decousus H, et al. Effect of obesity on outcomes after fondaparinux, enoxaparin, or heparin treatment for acute venous thromboembolism in the Matisse trials. J Thromb Haemost. 2007;5(6):1191–4.CrossRefGoogle Scholar
  17. 17.
    Heizmann M, Baerlocher GM, Steinmann F, et al. Anti-Xa activity in obese patients after double standard dose of nadroparin for prophylaxis. Thromb Res. 2002;106(4–5):179–81.CrossRefGoogle Scholar
  18. 18.
    Borkgren-Okonek MJ, Hartm DR, Pantanom DJ, et al. Enoxaparin thromboprophylaxis in gastric bypass patients: extended duration, dose stratification, and antifactor Xa activity. Surg Obes Relat Dis. 2008;4(5):625–31.CrossRefGoogle Scholar
  19. 19.
    Green B, Duffull SB. What is the best size descriptor to use for pharmacokinetic studies in the obese? Br J Clin Pharmacol. 2004;58(2):119–33.CrossRefGoogle Scholar
  20. 20.
    Barras MA, Duffull SB, Atherton JJ, et al. Individualized compared with conventional dosing of enoxaparin. Clin Pharmacol Ther. 2008;83(6):882–8.CrossRefGoogle Scholar
  21. 21.
    Paige JT, Gouda BP, Gaitor-Stampley V, et al. No correlation between anti-factor Xa levels, low-molecular-weight heparin, and bleeding after gastric bypass. Surg Obes Relat Dis. 2007;3(4):469–75.CrossRefGoogle Scholar
  22. 22.
    Buller HR, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):401S–428S.CrossRefGoogle Scholar
  23. 23.
    Pedersen PC, Ostergaard PB, Hedner U, et al. Pharmacokinetics of a low molecular weight heparin, logiparin, after intravenous and subcutaneous administration to healthy volunteers. Thromb Res. 1991;61(5–6):477–87.CrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2009

Authors and Affiliations

  • Jeroen Diepstraten
    • 1
  • Simone van Kralingen
    • 2
  • Repke J. Snijder
    • 3
  • Christian M. Hackeng
    • 4
  • Bert van Ramshorst
    • 5
  • Catherijne A. J. Knibbe
    • 1
  1. 1.Department of Clinical PharmacySt. Antonius HospitalNieuwegeinThe Netherlands
  2. 2.Department of AnaesthesiologySt. Antonius HospitalNieuwegeinThe Netherlands
  3. 3.Department of Pulmonary DiseasesSt. Antonius HospitalNieuwegeinThe Netherlands
  4. 4.Department of Clinical ChemistrySt. Antonius HospitalNieuwegeinThe Netherlands
  5. 5.Department of SurgerySt. Antonius HospitalNieuwegeinThe Netherlands

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