Gregory Egan1, Mary H H Ensom2. 1. BScPharm, ACPR, PharmD, is a Clinical Pharmacy Specialist in Neurology, Vancouver General Hospital, Vancouver, British Columbia. 2. BS(Pharm), PharmD, FASHP, FCCP, FCSHP, FCAHS, is a Professor in the Faculty of Pharmaceutical Sciences and Distinguished University Scholar, The University of British Columbia, and a Clinical Pharmacy Specialist, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia. She is also the Editor of the CJHP .
Abstract
BACKGROUND: The choice of whether to monitor anti-factor Xa (anti-Xa) activity in patients who are obese and who are receiving low-molecular-weight heparin (LMWH) therapy is controversial. To the authors' knowledge, no systematic review of monitoring of anti-Xa activity in such patients has been published to date. OBJECTIVE: To systematically ascertain the utility of monitoring anti-Xa concentrations for LMWH therapy in obese patients. DATA SOURCES: MEDLINE (1946 to September 2014), the Cochrane Database of Systematic Reviews, Embase (1974 to September 2014), PubMed (1947 to September 2014), International Pharmaceutical Abstracts (1970 to September 2014), and Scopus were searched using the terms obesity, morbid obesity, thrombosis, venous thrombosis, embolism, venous thromboembolism, pulmonary embolism, low-molecular weight heparin, enoxaparin, dalteparin, tinzaparin, anti-factor Xa, anti-factor Xa monitoring, anti-factor Xa activity, and anti-factor Xa assay. The reference lists of retrieved articles were also reviewed. STUDY SELECTION AND DATA EXTRACTION: English-language studies describing obese patients treated with LMWH or reporting anti-Xa activity were reviewed using a 9-step decision-making algorithm to determine whether monitoring of LMWH therapy by means of anti-Xa activity in obesity is warranted. Studies published in abstract form were excluded. DATA SYNTHESIS: The analysis showed that anti-Xa concentrations are not strongly associated with thrombosis or hemorrhage. In clinical studies of LMWH for thromboprophylaxis in bariatric surgery, orthopedic surgery, general surgery, and medical patients, and for treatment of venous thrombo embolism and acute coronary syndrome, anti-Xa activity can be predicted from dose of LMWH and total body weight; no difference in clinical outcome was found between obese and non-obese participants. CONCLUSIONS: Routinely determining anti-Xa concentrations in obese patients to monitor the clinical effectiveness of LMWH is not warranted on the basis of the current evidence. Circumstances where measurement of anti-Xa concentration may help in clinical decision-making in either obese or non-obese patients would be cases where elimination of LMWH is impaired or there is an unexpected clinical response, as well as to confirm compliance with therapy or to identify deviation from predicted pharmacokinetics.
BACKGROUND: The choice of whether to monitor anti-factor Xa (anti-Xa) activity in patients who are obese and who are receiving low-molecular-weight heparin (LMWH) therapy is controversial. To the authors' knowledge, no systematic review of monitoring of anti-Xa activity in such patients has been published to date. OBJECTIVE: To systematically ascertain the utility of monitoring anti-Xa concentrations for LMWH therapy in obesepatients. DATA SOURCES: MEDLINE (1946 to September 2014), the Cochrane Database of Systematic Reviews, Embase (1974 to September 2014), PubMed (1947 to September 2014), International Pharmaceutical Abstracts (1970 to September 2014), and Scopus were searched using the terms obesity, morbid obesity, thrombosis, venous thrombosis, embolism, venous thromboembolism, pulmonary embolism, low-molecular weight heparin, enoxaparin, dalteparin, tinzaparin, anti-factor Xa, anti-factor Xa monitoring, anti-factor Xa activity, and anti-factor Xa assay. The reference lists of retrieved articles were also reviewed. STUDY SELECTION AND DATA EXTRACTION: English-language studies describing obesepatients treated with LMWH or reporting anti-Xa activity were reviewed using a 9-step decision-making algorithm to determine whether monitoring of LMWH therapy by means of anti-Xa activity in obesity is warranted. Studies published in abstract form were excluded. DATA SYNTHESIS: The analysis showed that anti-Xa concentrations are not strongly associated with thrombosis or hemorrhage. In clinical studies of LMWH for thromboprophylaxis in bariatric surgery, orthopedic surgery, general surgery, and medical patients, and for treatment of venous thrombo embolism and acute coronary syndrome, anti-Xa activity can be predicted from dose of LMWH and total body weight; no difference in clinical outcome was found between obese and non-obeseparticipants. CONCLUSIONS: Routinely determining anti-Xa concentrations in obesepatients to monitor the clinical effectiveness of LMWH is not warranted on the basis of the current evidence. Circumstances where measurement of anti-Xa concentration may help in clinical decision-making in either obese or non-obesepatients would be cases where elimination of LMWH is impaired or there is an unexpected clinical response, as well as to confirm compliance with therapy or to identify deviation from predicted pharmacokinetics.
Entities:
Keywords:
anti-Xa; anti–factor Xa; low-molecular-weight heparin; therapeutic drug monitoring
Authors: Nils Kucher; Alain Leizorovicz; Paul T Vaitkus; Alexander T Cohen; Alexander G G Turpie; Carl-Gustav Olsson; Samuel Z Goldhaber Journal: Arch Intern Med Date: 2005-02-14
Authors: A G Turpie; M N Levine; J Hirsh; C J Carter; R M Jay; P J Powers; M Andrew; R D Hull; M Gent Journal: N Engl J Med Date: 1986-10-09 Impact factor: 91.245
Authors: A Berges; S Laporte; M Epinat; P Zufferey; E Alamartine; B Tranchand; H Decousus; P Mismetti Journal: Br J Clin Pharmacol Date: 2007-05-17 Impact factor: 4.335
Authors: R J Eck; J J C M van de Leur; R Wiersema; E G M Cox; W Bult; A J Spanjersberg; I C C van der Horst; M V Lukens; R O B Gans; K Meijer; F Keus Journal: Sci Rep Date: 2022-10-18 Impact factor: 4.996
Authors: Daniel M Witt; Robby Nieuwlaat; Nathan P Clark; Jack Ansell; Anne Holbrook; Jane Skov; Nadine Shehab; Juliet Mock; Tarra Myers; Francesco Dentali; Mark A Crowther; Arnav Agarwal; Meha Bhatt; Rasha Khatib; John J Riva; Yuan Zhang; Gordon Guyatt Journal: Blood Adv Date: 2018-11-27
Authors: Carlos José Goslan; Giórgio Alfredo Pedroso Baretta; Hemuara Grasiela Pestana de Souza; Bruna Zanin Orsi; Esdras Camargo A Zanoni; Marco Antonio Gimenez Lopes; Carlos Alberto Engelhorn Journal: J Vasc Bras Date: 2018 Jan-Mar