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Di Mauro AL, Austin LJ, Zande J, Winckel K, Neale R, De Guzman KR. Real-world comparative effectiveness of dalteparin and enoxaparin for venous thromboembolism prophylaxis. Blood Coagul Fibrinolysis 2024; 35:101-107. [PMID: 38358899 DOI: 10.1097/mbc.0000000000001281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Venous thromboembolism (VTE) is a preventable cause of significant morbidity and mortality in hospitalized patients world-wide. In Australia, the low-molecular weight heparins (LMWHs) enoxaparin or dalteparin are usually used as first-line prophylaxis for VTE, though there is uncertainty whether dalteparin has the same effectiveness as enoxaparin in real-world settings. This is relevant because dalteparin is less renally cleared and may be more cost effective than enoxaparin. The aim of this study was to explore VTE event incidence in a general cohort of hospitalized adult inpatients who were prescribed enoxaparin or dalteparin for VTE prophylaxis. A retrospective observational study was conducted at a quaternary hospital in Brisbane, Australia, of patients who had experienced a hospital-acquired VTE from 1 September 2021 to 1 March 2023. Patients were identified from routinely collected data following an in-hospital VTE event, and further data was retrieved retrospectively from the integrated electronic Medical Record (ieMR). Incidence and type of VTE events, LMWH-prescribing patterns, and risk factors were assessed. The incidence of VTE events were similar across the dalteparin and enoxaparin cohorts (42.1 events/10 000 patients vs. 34.4 events/10 000 patients, respectively), although patients prescribed enoxaparin had a higher number of risk factors, particularly obesity and active cancer. Our research indicates comparable incidence of VTE in patients prescribed dalteparin compared with enoxaparin in an Australian hospital general cohort of adult inpatients. Dalteparin may be as effective as enoxaparin for VTE prophylaxis in a real-world cohort of patients, and as such dalteparin may be considered a suitable alternative to enoxaparin for VTE prophylaxis. Further research including large randomized controlled trials are required to confirm these results.
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Affiliation(s)
- Anna L Di Mauro
- Office of the Chief Clinical Information Officer, eHealth Queensland, Brisbane
| | - Lewis J Austin
- Pharmacy Department, Princess Alexandra Hospital, Woolloongabba
| | | | - Karl Winckel
- Pharmacy Department, Princess Alexandra Hospital, Woolloongabba
- School of Pharmacy, University of Queensland
| | - Rodney Neale
- Vascular Surgery & Medicine Department, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Keshia R De Guzman
- Pharmacy Department, Princess Alexandra Hospital, Woolloongabba
- School of Pharmacy, University of Queensland
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2
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A systematic review of the efficacy and safety of anticoagulants in advanced chronic kidney disease. J Nephrol 2022; 35:2015-2033. [PMID: 36006608 PMCID: PMC9584987 DOI: 10.1007/s40620-022-01413-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have an increased risk of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulants have not been studied in randomised controlled trials with CrCl < 30 ml/min. The objective of this review was to identify the impact of different anticoagulant strategies in patients with advanced CKD including dialysis. METHODS We conducted a systematic review of randomized controlled trials and cohort studies, searching electronic databases from 1946 to 2022. Studies that evaluated both thrombotic and bleeding outcomes with anticoagulant use in CrCl < 50 ml/min were included. RESULTS Our initial search yielded 14,503 papers with 53 suitable for inclusion. RCTs comparing direct oral anticoagulants (DOACs) versus warfarin for patients with VTE and CrCl 30-50 ml/min found no difference in recurrent VTE events (RR 0.68(95% CI 0.42-1.11)) with reduced bleeding (RR 0.65 (95% CI 0.45-0.94)). Observational data in haemodialysis suggest lower risk of recurrent VTE and major bleeding with apixaban versus warfarin. Very few studies examining outcomes were available for therapeutic and prophylactic dose low molecular weight heparin for CrCl < 30 ml/min. Findings for patients with AF on dialysis were that warfarin or DOACs had a similar or higher risk of stroke compared to no anticoagulation. For patients with AF and CrCl < 30 ml/min not on dialysis, anticoagulation should be considered on an individual basis, with limited studies suggesting DOACs may have a preferable safety profile. CONCLUSION Further studies are still required, some ongoing, in patients with advanced CKD (CrCl < 30 ml/min) to identify the safest and most effective treatment options for VTE and AF.
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Jaspers TCC, Keyany A, Maat B, Meijer K, van den Bemt PMLA, Khorsand N. Therapeutically dosed low molecular weight heparins in renal impairment: a nationwide survey. Eur J Clin Pharmacol 2022; 78:1469-1479. [PMID: 35715569 PMCID: PMC9365729 DOI: 10.1007/s00228-022-03344-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 05/25/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE International guidelines vary in their recommendations whether or not to reduce the therapeutic dose of low molecular weight heparins (LMWHs) in renal impairment. The use of anti-Xa monitoring as a basis of dose adjustments is also a matter of debate. As this may lead to variations in treatment policies, we aimed to study the treatment policies of therapeutically dosed LMWHs in renal impairment in Dutch hospitals. METHODS An 11-item survey was distributed between June 2020 and March 2021 to hospital pharmacists, representing Dutch hospital organisations. Primary outcomes were the dosing regimens of therapeutically dosed LMWHs in renally impaired patients. Secondary outcomes were the proportion of hospitals that used anti-Xa monitoring and the anti-Xa target range used. RESULTS There was a response from 56 of 69 (81%) Dutch hospital organisations where in each case a hospital pharmacist completed the survey. In these hospitals, 77 LMWH regimens were in use. In 76 of 77 (99%) regimens, a regular dose reduction was used at the start of treatment. Fifty-five of these hospitals used a dose reduction if estimated glomerular filtration rate (eGFR) < 50 ml/min and 17 used a dose reduction if eGFR < 30 ml/min. Anti-Xa levels were not routinely monitored in 40% of regimens, while 22% monitored anti-Xa if eGFR < 50 ml/min, 27% if eGFR < 30 ml/min and 10% in other eGFR cutoff values. Target ranges of 1.0-2.0 IU/ml (once daily) and 0.5/0.6-1.0 IU/ml (twice daily) were used in 69% of regimens that included monitoring of anti-Xa. CONCLUSION Treatment policies show substantial diversity in therapeutically dosed LMWHs in renally impaired patients. The most commonly used treatment regimen was a regular dose reduction if eGFR is < 50 ml/min, without anti-Xa monitoring.
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Affiliation(s)
- Tessa Corrine Catherina Jaspers
- Department of Hospital Pharmacy, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands.
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands.
| | - A Keyany
- Department of Hospital Pharmacy, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - B Maat
- Department of Hospital Pharmacy, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - K Meijer
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - P M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - N Khorsand
- Department of Hospital Pharmacy, OLVG, Amsterdam, The Netherlands
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Díaz Gómez E, Suárez Del Olmo D, Corregidor Luna L, Iglesias-Peinado I, García Díaz B. Haemorrhagic complications in patients with renal insufficiency during treatment or prophylaxis with dalteparin. Eur J Hosp Pharm 2020; 29:187-191. [PMID: 32920531 DOI: 10.1136/ejhpharm-2020-002262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/24/2020] [Accepted: 08/18/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Low-molecular-weight heparins are widely used in clinical practice for the treatment or prophylaxis of venous thromboembolism (VTE). As these drugs are eliminated mainly by renal means, any renal function impairment may lead to higher plasma concentrations and increase the risk of bleeding. This study aims to evaluate whether in clinical practice there is an increase in the occurrence of bleeding in patients with renal insufficiency (RI) during treatment or prophylaxis with dalteparin, and to analyse the risk factors potentially influencing the appearance of such bleeding events. METHODS Patients were sampled from the Universitary Severo Ochoa Hospital, Leganés, Spain. This was a retrospective cohort study with a 1 year inclusion period, conducted at a Spanish university hospital with 400 beds, on patients undergoing treatment or prophylaxis for VTE with dalteparin for a minimum of 3 days. The main outcome measure was the number of patients who had bleeding events, independently of their severity, during dalteparin administration in patients with RI. RESULTS 367 patients were included in the study. Bleeding occurred in 17.9% of patients in the group with RI and in 7.3% of patients with normal renal function (NRF). Most haemorrhages in both cohorts were grade 2 on the WHO scale (64.7% in the RI group and 69.2% in the NRF group). Logistic regression analysis allowed the presence of RI (MDRD-4 (Modification of Diet in Renal Disease) <50 mL/min) to be identified as a risk factor. CONCLUSION Patients with RI treated with dalteparin face a higher risk of bleeding than those with NRF, which seems to make it necessary to monitor and seek new dosage adjustments for these patients.Impact on practice statements: This study yields new data on dalteparin in RI, which has not been widely studied before.
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Affiliation(s)
- Estrella Díaz Gómez
- Pharmacy Department, Hospital Universitario Severo Ochoa, Leganes, Madrid, Spain
| | | | | | - Irene Iglesias-Peinado
- Department of pharmacology, Universidad Complutense de Madrid Facultad de Farmacia, Madrid, Comunidad de Madrid, Spain
| | - Benito García Díaz
- Pharmacy Department, Hospital Universitario Severo Ochoa, Leganes, Madrid, Spain
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La CC, Takeuchi LE, Abbina S, Vappala S, Abbasi U, Kizhakkedathu JN. Targeting Biological Polyanions in Blood: Strategies toward the Design of Therapeutics. Biomacromolecules 2020; 21:2595-2621. [DOI: 10.1021/acs.biomac.0c00654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Caputo HE, Straub JE, Grinstaff MW. Design, synthesis, and biomedical applications of synthetic sulphated polysaccharides. Chem Soc Rev 2019; 48:2338-2365. [DOI: 10.1039/c7cs00593h] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This review summarizes the synthetic methods to sulphated polysaccharides, describes their compositional and structural diversity in regards to activity, and showcases their biomedical applications.
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Affiliation(s)
| | | | - Mark W. Grinstaff
- Department of Chemistry
- Boston University
- Boston
- USA
- Department of Biomedical Engineering
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Yu L, Guo X, Jia S, Xiang Y, Ding Z, Guo R. Pharmacodynamic properties and bioequivalence of dalteparin sodium subcutaneous injection in healthy Chinese male subjects. Xenobiotica 2018; 48:376-381. [PMID: 28375032 DOI: 10.1080/00498254.2017.1316021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
1. Dalteparin sodium (DS) is a low molecular weight heparin that is widely used in the treatment of thromboembolism. The purpose of this study was to compare the pharmacodynamic properties and bioequivalence of the two formulations of DS with subcutaneous injection in healthy Chinese male subjects. 2. In this randomized, open-label, two-period crossover study, a total of 24 male subjects were recruited to receive single subcutaneous doses of test and reference DS injection in two different sequences (12 subjects each) with a seven-day washout period. Plasma samples were obtained at different time points after administration of the injection and measured by chromogenic substrate assay. The pharmacodynamic parameters including Emax, AUEC0-T, AUEC0-∞ and Tmax were analyzed to evaluate the bioequivalence of two DS formulations. 3. The relative bioequivalence was 107.7 ± 15.5 and 106.6 ± 29.8 for Anti-Xa and Anti-IIa, two major active metabolites of DS, respectively. The 90% confidence intervals (CIs) of the geometric mean ratio (test/reference) of Emax, AUEC0-T and AUEC0-∞ were 98.71-104.40%, 101.95-112.13% and 102.38-112.10% for Anti-Xa, and 100.88-110.42%, 95.76-112.62% and 92.24-111.32% for Anti-IIa, respectively, and all of the 90% CIs were within 80-125%. The T1/2 of reference and test were 2.88 ± 1.21 h and 2.76 ± 0.97 h for Anti-Xa, 1.87 ± 0.62 h and 1.96 ± 1.52 h for Anti-IIa. 4. Based on the pharmacodynamic parameters and FDA Guidance on DS and regulatory criteria for bioequivalence, the test and reference formulations were bioequivalent in healthy Chinese male subjects.
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Affiliation(s)
- Lijin Yu
- a Department of Pharmacy , The Third Xiangya Hospital, Central South University , Changsha , China and
| | - Xin Guo
- a Department of Pharmacy , The Third Xiangya Hospital, Central South University , Changsha , China and
| | - Sujie Jia
- a Department of Pharmacy , The Third Xiangya Hospital, Central South University , Changsha , China and
| | - Yuanyuan Xiang
- a Department of Pharmacy , The Third Xiangya Hospital, Central South University , Changsha , China and
| | - Zhigang Ding
- b Department of Central Laboratory , The Third Xiangya Hospital, Central South University , Changsha , China
| | - Ren Guo
- a Department of Pharmacy , The Third Xiangya Hospital, Central South University , Changsha , China and
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Abstract
Current guidelines recommend low-molecular-weight heparin treatment in patients with cancer with established venous thromboembolism (VTE). The aim of this article was to study the pharmacological properties and effectiveness of tinzaparin in patients with cancer as well as its potential anticancer properties. A search of PubMed and ScienceDirect databases up to March 2016 was carried out to identify published studies that detect the properties and use of tinzaparin in oncology. Protamine sulfate partially (60% to 65%) neutralized tinzaparin’s anti-Xa activity. No dose adjustment of tinzaparin is needed even in patients with severe renal impairment and Creatinine Clearance ≥20 mL/min. Tinzaparin demonstrated a statistically significant decline in VTE recurrence at 1 year post the index thromboembolic event. A statistically significant reduction in minor bleeding rates was also described, whereas major bleeding events did not decrease in patients with cancer treated with tinzaparin versus those who received vitamin K antagonists. Tinzaparin treatment in patients suffering from deep vein thrombosis reduced the incidence of postthrombotic syndrome and venous ulcers. Tinzaparin’s ability to prevent both metastatic dissemination of cancer cells and tumor angiogenesis has been delineated in preclinical research. Current data show that tinzaparin is safe and efficacious either for short-term or for long-term treatment of VTE in patients with cancer. Clinical trials are needed in order to examine the utility of tinzaparin in primary prevention of VTE and validate its potential anticancer advantages exhibited in preclinical research.
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Affiliation(s)
- Evangelos P Dimakakos
- 1 Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Ioannis Vathiotis
- 1 Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Konstantinos Syrigos
- 1 Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
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Abstract
Patients with chronic kidney disease (CKD) are at risk for complications both inherent to the disease and as a consequence of its treatment. The dangers that CKD patients face change across the spectrum of the disease. Providers who are well-versed in these safety threats are best poised to safeguard patients as their CKD progresses.
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Affiliation(s)
- Lee-Ann Wagner
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Jeffrey C Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.
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Ribic C, Crowther M. Thrombosis and anticoagulation in the setting of renal or liver disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:188-195. [PMID: 27913479 PMCID: PMC6142494 DOI: 10.1182/asheducation-2016.1.188] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Thrombosis and bleeding are among the most common causes of morbidity and mortality in patients with renal disease or liver disease. The pathophysiology underlying the increased risk for venous thromboembolism and bleeding in these 2 populations is distinct, as are considerations for anticoagulation. Anticoagulation in patients with kidney or liver disease increases the risk of bleeding; this risk is correlated with the degree of impairment of anticoagulant elimination by the kidneys and/or liver. Despite being in the same pharmacologic category, anticoagulant agents may have varied degrees of renal and liver metabolism. Therefore, specific anticoagulants may require dose reductions or be contraindicated in renal impairment and liver disease, whereas other drugs in the same class may not be subject to such restrictions. To minimize the risk of bleeding, while ensuring an adequate therapeutic effect, both appropriate anticoagulant drug choices and dose reductions are necessary. Renal and hepatic function may fluctuate, further complicating anticoagulation in these high-risk patient groups.
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Affiliation(s)
- Christine Ribic
- Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University, and St Joseph's Healthcare, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University, and St Joseph's Healthcare, Hamilton, ON, Canada
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Crowther M, Lim W. Use of Low Molecular Weight Heparins in Patients with Renal Failure; Time to Re-evaluate Our Preconceptions. J Gen Intern Med 2016; 31:147-148. [PMID: 26658933 PMCID: PMC4720638 DOI: 10.1007/s11606-015-3525-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Mark Crowther
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- St Joseph's Hospital, Room L208, 50 Charlton Ave East, Hamilton, ON, Canada, L8N 4A6
| | - Wendy Lim
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
- St Joseph's Hospital, Room L208, 50 Charlton Ave East, Hamilton, ON, Canada, L8N 4A6.
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