If Some is Good, More is Better: An Enoxaparin Dosing Strategy to Improve Pharmacologic Venous Thromboembolism Prophylaxis.

BACKGROUND: Empiric enoxaparin dosing is inadequate for most trauma patients, leading to below target initial anti-Xa levels and requiring dose-adjustment for optimal venous thromboembolism (VTE) prophylaxis. We hypothesize that patient factors affecting initial anti-Xa levels can be identified based on drug pharmacokinetics, allowing creation of a new dosing protocol that will provide a higher percentage of in-target (0.2-0.4 IU/mL) patients at initial anti-Xa level assessment. METHODS: Records of 318 trauma patients were evaluated, and NONMEM and PSN software used to analyze 11 variables for their effects on anti-Xa levels. Computer modeling was used to select a new dosing protocol, which was implemented on the trauma service as a quality improvement project. The first 145 patients appropriately enrolled were assessed for response and complications. RESULTS: Only 29.5% of the pre-intervention group had initial anti-Xa levels in the appropriate prophylactic range (Figure1). Levels were most strongly influenced by patient weight, outweighing contributions from all other variables. A new regimen for initial dosing was therefore designed with three weight-defined categories for ease of administration. The post-intervention group showed an increase in in-target initial anti-Xa levels to 74.5% (p

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