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Evaluation of Safety and Efficacy of Venous Thromboembolism Prophylaxis with Unfractionated Heparin versus Enoxaparin in Obese Patients
Thursday April 24, 2025 11:20am - 11:35am EDT
Parthenon 1
Title:  Evaluation of Safety and Efficacy of Venous Thromboembolism Prophylaxis with Unfractionated Heparin versus Enoxaparin in Obese Patients
Authors:  Danielle Wilson; Rebecca Rainess
Residency: AdventHealth Orlando
 
Background/Purpose: Venous thromboembolism (VTE) is a major cause of inpatient mortality. Obesity has been shown to be a strong, independent risk factor for the development and recurrence of VTE. Anticoagulation dosing strategies for extremes of body habitus are controversial and inconsistent across guidelines. Current literature has mainly included bariatric surgical patients as the study population and evaluation of VTE prophylaxis dosing strategies in overall hospitalized patients with obesity is lacking. The objective of this study was to evaluate the safety and efficacy of parenteral agents utilized for VTE prevention in hospitalized patients with obesity.
 
Methods: This study was a multi-center, retrospective chart review of adult obese patients with a body mass index (BMI) greater than 30 kg/m2 that received parenteral anticoagulation for VTE prophylaxis at an AdventHealth Central Florida division or West Florida division hospital between March 1st, 2024, and August 31st, 2024. Patients who were pregnant, diagnosed with a hypercoagulable state, had history of heparin induced thrombocytopenia (HIT), developed HIT during the encounter, had a baseline of less than 50,000 platelets per microliter, and those who missed ≥ 2 doses of parenteral anticoagulation within a 48-hour period while the medication order was active were excluded. Augmented dosing strategies were defined as heparin 7,500 units subcutaneous (SQ) every 8 hours and enoxaparin ≥ 40 mg SQ every 12 hours. Traditional dosing strategies were defined as heparin 5,000 units SQ every 8 hours, enoxaparin 30 mg SQ every 12 hours, and enoxaparin 40 mg SQ daily. The primary outcome was the occurrence of VTE during hospitalization. Secondary outcomes included incidence of bleeding events and mortality. Bleeding events were further categorized into major and minor bleeding events. 
 
Results: A total of 1,131 patients were screened, 523 patients did not meet inclusion criteria and 348 were excluded to achieve a sample size of 260 patients. Baseline characteristics of the entire sample include a mean age of 58 (± 14) years, 104 (40.0%) were male, 137 (52.7%) were Caucasian, and 31 (11.9%) had a reported history of VTE. The median weight and BMI of the sample were 130.5 kg and 46.1 kg/m2, respectively. The augmented dosing cohorts included patients with greater BMI and younger ages as opposed to the traditional dosing cohorts. There was not a significant difference in occurrence of VTE events during hospitalization between the augmented and traditional dosing cohorts, with one VTE event occurring in each group (p = 1.00). Incidence of bleeding events were also not significantly different between the augmented dosing cohort and traditional dosing cohort, with three reported minor bleeding events occurring in both groups (p = 1.00). When comparing the two anticoagulants, the incidence of VTE events were the same (p = 1.00). However, 4 minor bleeding events occurred in the group receiving heparin while the enoxaparin group had 2 reported minor bleeding events (p = 0.41). There were no mortalities reported due to major bleeding or VTE event.
 
Conclusion: In this study of hospitalized patients with obesity, there were no differences found between the incidences of VTE events nor bleeding events when comparing augmented parenteral anticoagulant dosing strategies to traditional dosing strategies for VTE prophylaxis. 
 
Presentation Objective: Describe the factors that increase the risk of thrombosis in patients with obesity.
 
Self-Assessment: What of the following is not a mechanism that contributes to an increased risk of thrombosis in patients with obesity?
  1. Decreased activation of platelets
  2. Pro-inflammatory properties of adipose tissue
  3. Alterations of pharmacokinetic and pharmacodynamic properties of anticoagulants
  4. Increased adhesiveness of platelets


Moderators
GA
Presenters
avatar for Danielle Wilson

Danielle Wilson

PGY1 Resident, AdventHealth Orlando
Danielle is currently a PGY1 resident at AdventHealth Orlando. Danielle obtained her doctorate in Pharmacy from the University of Florida College of Pharmacy. She will be staying with AdventHealth Orlando next year as a PGY2 resident in Critical Care.
Evaluators
HB
Thursday April 24, 2025 11:20am - 11:35am EDT
Parthenon 1
  Internal Medicine (IM), AdventHealth Orlando
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