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Pharmacy Practice (Granada)

versão On-line ISSN 1886-3655versão impressa ISSN 1885-642X

Pharmacy Pract (Granada) vol.18 no.1 Redondela Jan./Mar. 2020  Epub 27-Abr-2020

https://dx.doi.org/10.18549/pharmpract.2020.1.1808 

Letter to the Editor

Value of venous thromboembolism prophylaxis by enoxaparin with anti-factor Xa trough concentration monitoring in surgical care

Seeba Zachariah (orcid: 0000-0003-2568-0244)1  , Maitha Al-Tamimi (orcid: 0000-0001-6374-9017)2  , Prasanna Vippadapu (orcid: 0000-0003-3897-5201)2  , Wessa Shenouda (orcid: 0000-0002-5979-6408)3  , Dixon Thomas (orcid: 0000-0002-1963-253X)4 

1 PhD, MPharm. Clinical Lecturer. Department of Pharmacy Practice, College of Pharmacy, Gulf Medical University. Ajman (United Arab Emirates).

2BPharm. Department of Pharmacy Practice, College of Pharmacy, Gulf Medical University. Ajman (United Arab Emirates).

3Department of Pharmacy Practice, College of Pharmacy, Gulf Medical University. Ajman (United Arab Emirates).

4PhD, MPharm. Department of Pharmacy Practice, College of Pharmacy, Gulf Medical University. Ajman (United Arab Emirates).

Dear editor,

We read recently published an article in Pharmacy Practice; Pharmacist recommendations for prophylactic enoxaparin monitoring and dose adjustment in trauma patients admitted to a surgical intensive care unit by Scrimenti et al. This study aimed to evaluate pharmacists’ recommendations for providing prophylactic enoxaparin treatment to trauma patients in the surgical intensive care unit (SICU), medical providers’ acceptance of the recommendations, and the clinical outcomes after implementing the anticoagulant therapy.1

We have concerns about the cost-effectiveness of monitoring anti-factor Xa trough concentrations (AFXa-TRs) in surgical intensive care venous thromboembolism (VTE) prophylaxis with enoxaparin. Correlation of interim outcome of levels of AFXa-TRs to the incidence of VTE need could be discussed as well. As discussed in the limitations of the study, not being patient-oriented is a major limitation as not ordering AFXa-TRs cannot be implied to the quality of practice of medical providers. Number needed to treat (NNT) shall be calculated to see in how many surgical intensive care patients, AFXa-TRs to be ordered to actually prevent an incidence of VTE. Future studies in this line might make a better clinical sense.

AFXa trough concentrations are better correlated to VTE predictability compared to peak concentrations. Still, AFXa-TRs range for therapeutic is defined well in literature, but the prophylactic ranges are not clear yet. Studies in trauma patients found that subprophylactic AFXa-TRs were common among the patients and dosage adjustment resulted in a reduced rate of VTE without an increased risk of bleeding.2 Based on Greenfield’s Risk Assessment Profile score, prophylaxis with enoxaparin monitoring using AFXa-TRs reduced deep vein thrombosis incidence from 20.5% to 7.1% in high-risk trauma patients.3

The clinical advantage of enoxaparin over heparin is a lesser need for monitoring. This improves cost-effectiveness as expenses of monitoring, and chances of bleeding are less. Monitoring AFXa-TRs in any surgical intensive patients would result in a basic question; Does heparin with monitoring would be more cost-effective than enoxaparin with monitoring in surgical intensive care having continuous nursing support? Bleeding due to enoxaparin is not easy to reverse as compared to heparin-induced bleeding. In our opinion, as clinical pharmacists, we should be patient-oriented than physician oriented to implement cost-effective and safe therapy proven with clinically relevant outcomes.

Ohta et al. evaluated the risk factors of postoperative bleeding after elective surgery for patients with primary colorectal cancer receiving pharmacological thromboprophylaxis of enoxaparin. The significant differences in the type of thromboprophylaxis were observed between postoperative bleeding-negative and bleeding-positive group. However, no statistical significance was found, which questions the need for thromboprophylaxis in trauma patients.3 In addition, Sun et al. observed that the incidence of VTE was higher with low molecular weight heparins (LMWH) than factor Xa inhibitors, specifically in total hip or total knee arthroplasty.4

We hope these comments would be useful in the continuation of studies on the prophylactic utility of enoxaparin in surgical care and how pharmacists make a difference in improving patient outcomes. Naturally medical or nursing providers would accept what is best for the patients. The accountability of pharmacists’ interventions is studied and scrutinized.

REFERENCES

1. Scrimenti A, Seabury RW, Miller CD, Ruangvoravat L, Darko W, Probst LA, Cwikla GM. Pharmacist recommendations for prophylactic enoxaparin monitoring and dose adjustment in trauma patients admitted to a surgical intensive care unit. Pharm Pract (Granada). 2019;17(4):1541. https://doi.org/10.18549/PharmPract.2019.4.1541 [ Links ]

2. Ko A, Harada MY, Barmparas G, Chung K, Mason R, Yim DA, Dhillon N, Margulies DR, Gewertz BL, Ley EJ. Association between enoxaparin dosage adjusted by anti–factor Xa trough level and clinically evident venous thromboembolism after trauma. JAMA Surg. 2016;151(11):1006-1013. https://doi.org/10.1001/jamasurg.2016.1662 [ Links ]

3. Singer GA, Riggi G, Karcutskie CA, Vaghaiwalla TM, Lieberman HM, Ginzburg E, Namias N, Lineen EB. Anti-Xa–guided enoxaparin thromboprophylaxis reduces rate of deep venous thromboembolism in high-risk trauma patients. J Trauma Acute Care Surg. 2016;81(6):1101-1108. https://doi.org/10.1097/TA.0000000000001193 [ Links ]

4. Ohta H, Miyake T, Shimuzu T, Sonoda H, Ueki T, Kaida S, Yamaguchi T, Iida H, Tani M. The impact of pharmacological thromboprophylaxis and disease-stage on postoperative bleeding following colorectal cancer surgery. World J Surg Oncol. 2019 Jun 27;17(1):110. https://doi.org/10.1186/s12957-019-1653-1 [ Links ]

5. Sun G, Wu J, Wang Q, Liang Q, Jia J, Cheng K, Sun G, Wang Z. Factor Xa inhibitors and direct thrombin inhibitors versus low-molecular-weight heparin for thromboprophylaxis after total hip or total knee arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty. 2019;34(4):789-800. https://doi.org/10.1016/j.arth.2018.11.029 [ Links ]

FUNDING: No funds received

Received: January 11, 2020; Accepted: February 05, 2020; pub: February 17, 2020

CONFLICT OF INTEREST

None reported by all authors

Seeba ZACHARIAH: seebadixon@gmail.com

Maitha AL-TAMIMI: phmaitha@hotmail.com

Prasanna VIPPADAPU: prasannav267@gmail.com

Wessa SHENOUDA: wessa.wasfy@gmail.com

Dixon THOMASdixon.thomas@gmail.com

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY-NC-ND 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.