Recent updates in the management of thromboembolism - MediBytes November 2021 newsletter
In an observational cohort study by Martinelli I et al. (2021)1 with COVID-19 respiratory illness patients, a 60% reduction in mortality and clinical deterioration and a 50% reduction in venous thromboembolism (VTE) compared to standard dosage prophylaxis were observed with enoxaparin.
Patients on standard dosage prophylaxis received enoxaparin 40 mg daily increased to 60 mg daily in obese. Patients in the ICU received 1 mg/kg twice daily, those in high-intensity of care wards received 0.7 mg/kg twice daily, and those in low-intensity of care wards received 1 mg/kg daily.
GARFIELD-VTE2 is a prospective, non-interventional study of 10,869 patients with objectively confirmed VTE. Patients were grouped according to body mass index: <18.5 (underweight; n=214); 18.5–24.9 (normal; n=2,866); 25.0–29.9 (overweight; n=3,326); ≥30 (obese; n=3,073).
Underweight patients with VTE were found to have the highest risk of mortality and major bleeding. The mortality risk in obese patients with VTE is lower than that in normal body mass index patients with VTE
Martin MA et al.3 in a single-center, retrospective observational study demonstrated body mass index-stratified therapeutic enoxaparin dosing regimen in obese patients. Fixed dosing without monitoring may not be appropriate. Thromboprophylaxis with 40 mg BID in obese patients was efficacious in preventing VTE without excess bleeding compared to control patients
In a recent review by Schmidt RA et al. (2021),4 treatment options for cancer-associated VTE were evaluated. There have been no head-to-head trials comparing different direct oral anticoagulants in this setting, and randomized trials comparing a direct oral anticoagulant with low molecular weight heparin dalteparin differ in trial design and results
Another recently published article by Falanga A et al. (2021)5 had a similar view. As mentioned in this article, randomized clinical trial data with head-to-head comparisons between direct oral anticoagulants and low molecular weight heparins showed that overall direct oral anticoagulants had a similar efficacy profile; however, a higher risk of bleeding was observed in some of these studies.
Long-term therapy with low molecular weight heparin has been the standard of care for the treatment of cancer-associated VTE given its favorable risk–benefit ratio compared to vitamin K antagonists.
- Martinelli I, Ciavarella A, Abbattista M, et al. Increasing dosages of low-molecular-weight heparin in hospitalized patients with Covid-19. Intern Emerg Med. 2021 Aug;16(5):1223–1229.
- Weitz JI, Farjat AE, Ageno W, et al; GARFIELD-VTE Investigators. Influence of body mass index on clinical outcomes in venous thromboembolism: Insights from GARFIELD-VTE. J Thromb Haemost. 2021 Dec;19(12):3031–3043.
- Martin AM, Polistena P, Mahmud A, et al. Optimal enoxaparin dosing strategies for venous thromboembolism prophylaxis and treatment of high body weight patients. Thromb Res. 2021 Sep 22;207:116–122.
- Schmidt RA, Lee AY. How I treat and prevent venous thrombotic complications in patients with lymphoma. Blood. 2021 Sep 3:blood.2019003689. Epub ahead of print. PMID: 34479364.
- Falanga A, Gal GL, Carrier M, et al. Management of cancer-associated thrombosis: Unmet needs and future perspectives. TH Open. 2021 Jul 1;5(3):e376–e386.