Hospital Pharmacy - December 2019 - 375

375

Hanni et al
Table 1. Anticoagulant Dosing by Hospital Day.
Treatment day

INR

Warfarin dose (mg)

Bridge therapy

Lab monitoring

1
2
3
4
5
6
7a

1.08
1.1
1.24
1.50
1.71
2.17
2.2

10
10
7.5
10
10
10
10

Heparin IV 2600 units/hr
Heparin IV 2800 units/hr
Enoxaparin SQ 200 mg every 12 hr
Enoxaparin SQ 200 mg every 12 hr
Enoxaparin SQ 200 mg every 12 hr
Enoxaparin SQ 200 mg every 12 hr
Enoxaparin SQ 200 mg every 12 hr

aPTT = 37.2 sec
aPTT = 57.8 sec

Anti-Xa = 1.01 IU/mL

Note. INR = International normalized ratio; IV = Intravenous; SQ = Subcutaneous; aPTT = Activated partial thromboplastin time; Sec = seconds;
Hr = hours.
a
Enoxaparin was discontinued on day 7 of treatment

Table 2. Studies Assessing Therapeutic Enoxaparin for VTE in Morbidly Obese Patients.
Citation

Study design,
(n)

Population

Enoxaparin
2

** Median BMI: 45.6 kg/m (36.892.1)
** Median weight: 138.1 kg (95.3266.7)
** Age (years, mean): 55.9
** Male gender: 48.8%
** Median BMI 49.5 kg/m2 (40.198.1)
** Median weight: 162 kg (106-243)
** Age (years, median): 45
** Male gender: 46%
** VTE indication: 73%
** Mean BMI: 50.6 kg/m2 (40-95.1)
** Mean weight: 146.3 kg (78-249)
** Age (years, mean): 57.8
** Male gender: 45%
** VTE indication: 37%
** Median BMI 46.2 kg/m2 (40.2-62)
** Median weight: 138 kg (105-197)
** Age (years, median): 61
** Male gender: 48%
** VTE indication: 65%
** BMI: ⩾40 kg/m2 (n): 100
** Max weight: 175.5 kg
** Age (years, mean): 50.3
** Male gender: 25%

ThompsonMoore8

Prospective
observational
cohort (41)

Deal9

Retrospective
cohort (26)

Lee10

Retrospective
cohort (99)

Lalama16,21

Retrospective
cohort (31)

Hagopian17,22

Retrospective
case-control
(300)

Heitlage23

Case Report

**
**
**
**

22 y/o female
BMI: 114 kg/m2
Total weight: 322 kg
Suspected PE

Mazhar24

Case Report

**
**
**
**

52 y/o male
BMI: 61 kg/m2
Total weight: 210 kg
Lower extremity DVT

Clinical outcomes/results

** Dosing:
** 0.90 mg/kg (range: 0.831.04)
** Maximum dose: 160 mg
** Goal anti-Xa level:
** 0.6 to 1.0 IU/mL
** Dosing
** Median: 0.8 mg/kg Q12
hours
** Range: 0.5-1.1 mg/kg
** Goal anti-Xa level:
** 0.5 to 1.1 IU/mL
** Dosing:
** 1.5 mg/kg Q12
** Or 1 mg/kg Q24
** Goal anti-Xa level:
** 0.5 to 1.1 IU/mL
** Dosing:
** 0.75 mg/kg Q12 hours
** Goal anti-Xa level:
** 0.6 to 1.1 IU/mL

** 38.9% achieved goal anti-Xa levels
** Enoxaparin median doses:
** Goal anti-Xa level: 0.83 mg/kg
** Above target anti-Xa: 0.98 mg/kg
** No difference in bleeding or thrombotic
events
** 46% achieved goal anti-Xa levels
** Above target anti-Xa: 38%
** Uninterpretable: 15%
** Overall 6 bleeding events occurred
** More common in above target group
(40% vs. 0%; p=0.033)
** 35.4% achieved goal anti-Xa levels
** Above target anti-Xa: 50.5%
** Below target anti-Xa: 14.1%
** No bleeding events occurred

** Dosing:
** ⩾ 0.85 mg/kg Q24 hours
or Q12 hours
** Maximum dose: 150 mg
** Goal anti-Xa level:
** Once daily: 1-2 IU/mL
** Twice daily: 0.5-1 IU/mL
** Initial Dosing:
** 160 mg BID
** Max dose based on
institution
** Goal anti-Xa level:
** 0.5 to 1.1 IU/mL
** Initial Dosing:
** 140 mg Q12 hours (0.67
mg/kg)
** Goal anti-Xa level:
** 0.5 to 1.0 IU/mL

** Anti-Xa levels not routinely obtained in
study
** No difference in bleeding events (p =
0.30)
** Morbidly obese bleeding events: 29%
** Control group bleeding events: 23.5%

** 48% achieved goal anti-Xa levels
** Above target anti-Xa: 36%
** Below target anti-Xa: 16%
** Two minor bleeding events reported

** Initial anti-Xa level low (0.4 IU/mL)
** Enoxaparin dose for goal anti-Xa level:
** 0.62 mg/kg Q12 hours
** Dose adjustments required: 1
** No adverse events reported
** Initial anti-Xa level low (0.37 IU/mL)
** Enoxaparin dose for goal anti-Xa level:
** 0.86 mg/kg Q12 hours
** Dose adjustments required: 2
** No adverse events reported

Note. QD = daily; BID = twice daily; BMI = body mass index; VTE = venous thromboembolism; Y/o = "year old"; DVT = deep vein thrombosis.

therefore an attractive option; however, evidence regarding
the optimal empiric dosing regimen for morbidly obese
patients is unclear, so prolonged hospitalization for anti-Xa
monitoring is still required by our institution. Published

evidence demonstrates a discrepancy between institutions
and practitioners as to whether weight-based dosing or "dose
capping" occurs.9,10,21,23,24 Studies demonstrate that morbidly
obese patients have high rates of supratherapeutic anti-Xa
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