Hospital Pharmacy - December 2020 - 366

848732
review-article2019

HPXXXX10.1177/0018578719848732Hospital PharmacyTran et al

Orignal Article

Prophylactic Enoxaparin Dosing in Obese
Orthopedic Patients: A Literature Search

Hospital Pharmacy
2020, Vol. 55(6) 366--372
© The Author(s) 2019
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https://doi.org/10.1177/0018578719848732
DOI: 10.1177/0018578719848732
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Van N. Tran1 , Ilya Varfolomeev2, and Geoff Hill3

Abstract
Objective: The objective of the study was to review the current literature for prophylactic enoxaparin dosing in obese
orthopedic patients. Method: A literature search was undertaken using OVID Medline, OVID Embase, and Cochrane Central
databases, accessed through hospital library websites. Key search terms (in UK and US spelling) included orthopaedics,
low-molecular-weight heparin, enoxaparin, venous thromboembolism prophylaxis, weight, obese, morbid obesity. Possible
related subheadings, such as bone, fractures, anticoagulants, overweight, body mass index, deep vein thrombosis, pulmonary
embolism, were also included in the database search to optimize the search strategies. The search was restricted to human
subjects and limited to articles published from 1998 to the present. Results: The search identified 429 potentially relevant
articles. Once duplicates were removed, 345 were screened for inclusion in this review. Only 3 articles (a case-control
study, an observational prospective study, and a case report) met both the inclusion and exclusion criteria. The findings
from this review need to be interpreted cautiously due to limitations in study designs and the potential for confounding
bias. Conclusion: The results of a multiple database search draw one to the conclusion that there is very limited evidence
in the literature with regard to prophylactic enoxaparin dosing in obese orthopedic-specific patients. Orthopedic patients
are among the highest risk of all surgical specialties for venous thromboembolism. There is strong evidence to support
an increased prophylactic low-molecular-weight heparin doses in obese patients; thus, the authors recommend higher
prophylactic enoxaparin dosing in obese orthopedic patients.
Keywords
orthopaedics/orthopedics, venous thromboembolism prophylaxis, obese, low-molecular-weight heparin, morbid obesity,
deep vein thrombosis, special populations

Introduction
Venous thromboembolism (VTE) is defined as a blood clot
formation in a deep vein.1 This includes deep vein thrombosis (DVT), usually found in the lower leg, and/or pulmonary
embolism (PE), where the clot breaks off and travels from
the leg up to the lungs. DVT and PE are serious, life-threatening conditions that require immediate medical attention.2
The risk of postoperative VTE in orthopedic patients is
among the highest of all surgical specialties.1 This risk correlates with both procedure and patient parameters. Several
procedure-related factors contribute to the risk of VTE in all
surgical patients including the extent and duration of surgery,
the type of anesthesia, and likelihood for immobilization and
casting postoperatively.2
Factors that are specific to patients undergoing major
orthopedic surgery that contribute to the increased risk of
VTE include obesity, older age >75 years (particularly ≥85
years), poor ambulation (prior to surgery), and cardiovascular disease.3 Highest risk procedures are reported in hip and
knee arthroplasty, hip fracture surgery, pelvic, and multiple
fractures.4 Lower risk procedures include minor orthopedic
procedures (eg, arthroscopic procedures, foot and ankle

surgery), where the patient cohort is generally younger and
more active.5
Obese patients are defined as those with a body mass
index (BMI) greater than or equal to 30 kg/m2 (refer to Table
1).6 Obesity has been demonstrated to be an independent risk
factor for VTE in both men and women.7 The risk for VTE in
obese patients is estimated at twice that of nonobese patients
and 6 times more likely in patients with a BMI greater than
35 kg/m2 or higher.8
Studies evaluating dosing regimens and Anti-Xa levels in
obese surgical gastric bypass patients with enoxaparin unanimously recommend an increased dose of enoxaparin ranging
from 30 to 60 mg subcutaneously twice daily as a prophylactic
dose.9 International guidelines {1, 2 ,3} stratify types of
1

Pharmacy Department, The Royal Melbourne Hospital, Victoria, Australia
Orthopaedic Department, The Royal Melbourne Hospital, Victoria, Australia
3
Health Sciences Library, The Royal Melbourne Hospital, Victoria, Australia
2

Corresponding Author:
Van N. Tran, Clinical Pharmacist, Pharmacy Department, The Royal
Melbourne Hospital, City Campus, Grattan Street, Parkville, Victoria
3050, Australia.
Email: van.nguyen2@mh.org.au


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Hospital Pharmacy - December 2020

Table of Contents for the Digital Edition of Hospital Pharmacy - December 2020

Drug Review Updated List of Light-Sensitive Oral Medications Scott Perkins, Adam Evans, and Allison King
Original Articles Prophylactic Enoxaparin Dosing in Obese Orthopedic Patients: A Literature Search Van N. Tran, Ilya Varfolomeev, and Geoff Hill
Significant Published Articles for Pharmacy Nutrition Support Practice in 2019 Roland N. Dickerson, Angela L. Bingham, Todd W. Canada, Lingtak N. Chan, M. Petrea Cober, Sarah V. Cogle, Anne M. Tucker, and Vanessa J. Kumpf
Effect of Therapeutic Interchange on Medication Changes Between Admission and Discharge Ryan A. Popp, Kathleen A. Lusk, Shelley S. Glaess, Donna Burkett, and Rebecca L. Attridge
Evaluating Six Commercially Available Closed-System Drug-Transfer Devices Against NIOSH’s 2015 Draft Vapor Protocol Shiraz Halloush, Ivan A. Reveles, and Jim Koeller
Adjusted vs Total Body Weight–Based Dosing of Sedation and Analgesia Used in the Intensive Care Unit Julianne Yeary, Alexandra Greco, Richard McKnight, Karen Petros, Gregory Schaefer, and Jeffrey Garavaglia
Medication Safety at Home: A Qualitative Study on Caregivers of Chronically Ill Children in Malaysia Chii-Chii Chew, Amar-Singh HSS, Huan-Keat Chan, and Mohamed Azmi Hassali
Hospital Pharmacy - December 2020 - Cover1
Hospital Pharmacy - December 2020 - Cover2
Hospital Pharmacy - December 2020 - 345
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Hospital Pharmacy - December 2020 - Drug Review Updated List of Light-Sensitive Oral Medications Scott Perkins, Adam Evans, and Allison King
Hospital Pharmacy - December 2020 - 350
Hospital Pharmacy - December 2020 - 351
Hospital Pharmacy - December 2020 - 352
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Hospital Pharmacy - December 2020 - 365
Hospital Pharmacy - December 2020 - Original Articles Prophylactic Enoxaparin Dosing in Obese Orthopedic Patients: A Literature Search Van N. Tran, Ilya Varfolomeev, and Geoff Hill
Hospital Pharmacy - December 2020 - 367
Hospital Pharmacy - December 2020 - 368
Hospital Pharmacy - December 2020 - 369
Hospital Pharmacy - December 2020 - 370
Hospital Pharmacy - December 2020 - 371
Hospital Pharmacy - December 2020 - 372
Hospital Pharmacy - December 2020 - Significant Published Articles for Pharmacy Nutrition Support Practice in 2019 Roland N. Dickerson, Angela L. Bingham, Todd W. Canada, Lingtak N. Chan, M. Petrea Cober, Sarah V. Cogle, Anne M. Tucker, and Vanessa J. Kumpf
Hospital Pharmacy - December 2020 - 374
Hospital Pharmacy - December 2020 - 375
Hospital Pharmacy - December 2020 - 376
Hospital Pharmacy - December 2020 - 377
Hospital Pharmacy - December 2020 - 378
Hospital Pharmacy - December 2020 - 379
Hospital Pharmacy - December 2020 - 380
Hospital Pharmacy - December 2020 - 381
Hospital Pharmacy - December 2020 - Effect of Therapeutic Interchange on Medication Changes Between Admission and Discharge Ryan A. Popp, Kathleen A. Lusk, Shelley S. Glaess, Donna Burkett, and Rebecca L. Attridge
Hospital Pharmacy - December 2020 - 383
Hospital Pharmacy - December 2020 - 384
Hospital Pharmacy - December 2020 - 385
Hospital Pharmacy - December 2020 - 386
Hospital Pharmacy - December 2020 - 387
Hospital Pharmacy - December 2020 - 388
Hospital Pharmacy - December 2020 - 389
Hospital Pharmacy - December 2020 - 390
Hospital Pharmacy - December 2020 - Evaluating Six Commercially Available Closed-System Drug-Transfer Devices Against NIOSH’s 2015 Draft Vapor Protocol Shiraz Halloush, Ivan A. Reveles, and Jim Koeller
Hospital Pharmacy - December 2020 - 392
Hospital Pharmacy - December 2020 - 393
Hospital Pharmacy - December 2020 - 394
Hospital Pharmacy - December 2020 - 395
Hospital Pharmacy - December 2020 - 396
Hospital Pharmacy - December 2020 - 397
Hospital Pharmacy - December 2020 - 398
Hospital Pharmacy - December 2020 - 399
Hospital Pharmacy - December 2020 - Adjusted vs Total Body Weight–Based Dosing of Sedation and Analgesia Used in the Intensive Care Unit Julianne Yeary, Alexandra Greco, Richard McKnight, Karen Petros, Gregory Schaefer, and Jeffrey Garavaglia
Hospital Pharmacy - December 2020 - 401
Hospital Pharmacy - December 2020 - 402
Hospital Pharmacy - December 2020 - 403
Hospital Pharmacy - December 2020 - 404
Hospital Pharmacy - December 2020 - Medication Safety at Home: A Qualitative Study on Caregivers of Chronically Ill Children in Malaysia Chii-Chii Chew, Amar-Singh HSS, Huan-Keat Chan, and Mohamed Azmi Hassali
Hospital Pharmacy - December 2020 - 406
Hospital Pharmacy - December 2020 - 407
Hospital Pharmacy - December 2020 - 408
Hospital Pharmacy - December 2020 - 409
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