Hospital guidelines for use of low-molecular-weight heparins

Characterization of Guideline Evidence for Off-label Medication Use in the Intensive Care Unit

BACKGROUND

Non-Food and Drug Administration (FDA) or off-label medication prescribing occurs commonly in the intensive care unit (ICU). Off-label medication use creates a concern for untoward adverse effects; however, this worry may be alleviated by supportive literature.

OBJECTIVE

To evaluate the evidence behind off-label medication use by determining the presence of guideline support and compare graded recommendations to an online tertiary resource, DRUGDEX.

METHODS

Off-label medication use was identified prospectively over 3 months in medical ICUs in 3 academic medical centers. Literature searches were conducted in PubMed and the national guideline clearinghouse website to determine the presence of guideline support. DRUGDEX was also searched for strength-of-evidence ratings to serve as a comparator.

RESULTS

A total of 287 off-label medication indication searches resulted in 44% (126/287) without identified evidence; 253 guidelines were identified for 56% (161/287) of indications. Of the published guidelines, 89% (226/253) supported the off-label indication. In the DRUGDEX comparison, 67% (97/144) of guideline gradings disagree with DRUGDEX, whereas 33% (47/144) of the gradings matched the online database.

CONCLUSION

Because more than half of off-label medication use has the benefit of supportive guidelines recommendations and a majority of gradings are inconsistent with DRUGDEX, clinicians should consider utilizing guidelines to inform off-label medication use in the ICU. Still, there is a considerable amount of off-label medication use in the ICU that lacks supporting evidence, and use remains concerning because it may lead to inappropriate treatment and adverse events.

Current dosing of low-molecular-weight heparins does not reflect licensed product labels: an international survey

AIMS

Low-molecular-weight heparins (LMWHs) are used globally to treat thromboembolic diseases; however, there is much debate on how to prescribe effectively for patients who have renal impairment and/or obesity. We aimed to investigate the strategies used to dose-individualize LMWH therapy.

METHODS

We conducted an online survey of selected hospitals in Australia, New Zealand (NZ), United Kingdom (UK) and the United States (US). Outcome measures included: the percentage of hospitals which recommended that LMWHs were prescribed according to the product label (PL), the percentage of hospitals that dose-individualized LMWHs outside the PL based on renal function, body weight and anti-Xa activity and a summary of methods used to dose-individualize therapy.

RESULTS

A total of 257 surveys were suitable for analysis: 84 (33%) from Australia, 79 (31%) from the UK, 73 (28%) from the US and 21 (8%) from NZ. Formal dosing protocols were used in 207 (81%) hospitals, of which 198 (96%) did not adhere to the PL. Of these 198 hospitals, 175 (87%) preferred to dose-individualize based on renal function, 128 (62%) on body weight and 48 (23%) by monitoring anti-Xa activity. All three of these variables were used in 29 (14%) hospitals, 98 (47%) used two variables and 71 (34%) used only one variable.

CONCLUSIONS

Dose-individualization strategies for LMWHs, which contravene the PL, were present in 96% of surveyed hospitals. Common individualization methods included dose-capping, use of lean body size descriptors to calculate renal function and the starting dose, followed by post dose anti-Xa monitoring.

Survey of hospitals for guidelines, policies, and protocols for anticoagulants

PURPOSE

A survey of community hospitals that are part of a national group purchasing organization (GPO) was conducted to assess the formulary status of currently available anticoagulants, assess the current status of anticoagulant prescribing guidelines and the existing scope of such guidelines, and identify perceptions about the appropriateness of the use of anticoagulants in community hospitals in the United States.

METHODS

A Web-based survey of acute care hospitals that were members of a leading health care resource management and GPO was conducted. The survey was sent to 224 hospitals.

RESULTS

Of 224 hospitals, 127 participated in the survey, a response rate of 59.6%. Warfarin, unfractionated heparin (UFH), and enoxaparin were the anticoagulants most commonly included (>80%) on the hospitals' drug formularies. Guidelines relating to the use of UFH and low-molecular-weight heparins (LMWHs) existed in approximately 87.4% and 55.1% of responding hospitals, respectively, followed by warfarin and direct thrombin inhibitors (DTIs) (approximately 44.1% and 30.7%, respectively). Among hospitals without guidelines, 78.2%, 72.1%, 65.4%, 50.0%, and 41.4% reported that such guidelines would be useful if they included LMWHs, warfarin, DTIs, UFH, and fondaparinux, respectively. Guidelines for prophylaxis of venous thromboembolism (VTE), appropriate drug selection, and dosing for VTE prophylaxis and treatment existed in 59.8%, 53.5%, and 43.3% of the hospitals, respectively.

CONCLUSION

The study found that a sizable percentage of the responding community hospitals did not have guidelines, protocols, or policies related to the use of anticoagulants. Further, those hospitals without such guidelines commonly reported a need for clinical practice guidelines.

Impact of Prescribing Guidelines for Inpatient Anticoagulation

BACKGROUND

Anticoagulants are widely used and represent a class of drugs that are problem-prone and have a high potential for adverse patient outcomes. As such, these drugs may be amenable to the use of prescribing guidelines. However, relatively little has been published on the effect of such guidelines on clinical outcomes or costs of care.

OBJECTIVE

To assess whether guidelines improve the appropriateness of prescribing, clinical outcomes, and costs associated with use of anticoagulants in a sample of community hospitals in the US.

METHODS

A retrospective analysis was performed of data voluntarily collected by 15 hospitals before (July—September 2001) and after (March—May 2002) implementation of anticoagulant prescribing guidelines. Statistical analyses of both patient- and hospital-level variables were conducted.

RESULTS

Implementation of the guidelines resulted in a significant increase in the proportion of anticoagulants that were prescribed appropriately (59.8% vs 86.9%; p < 0.001). The guidelines also resulted in a shift in the type of anticoagulants prescribed (decreased use of unfractionated heparin and increased use of low-molecular-weight heparins). There was suggestive evidence, although not statistically significant, that the guidelines resulted in fewer anticoagulant-associated adverse events (total bleeding RR 0.71) and lower costs (savings of $56.15 per patient per day).

CONCLUSIONS

While limitations existed with the study design, sufficient benefits were identified to warrant hospitals to consider use of these or similar guidelines on a routine basis. Clearly, additional study in this area would be useful.