Dataset Information

Protocolled Redefinition of the Therapeutic Range for Unfractionated Heparin: Lost in Translation?

ABSTRACT:

Background

Protocolled treatment with unfractionated heparin (UFH) is a subject of ongoing debate. Even though international guidelines prescribe calibration of the activated partial thromboplastin time (aPTT) to 0.3 to 0.7 U/mL anti-Xa activity to establish an UFH therapeutic range, evidence for this approach remains scarce. In this study, we evaluated different strategies to delineate the UFH therapeutic range and analyzed the effects on patient therapeutic classification.

Methods

In 109 patient samples, the aPTT was measured with 2 different reagents, both of which used mechanical clot detection. The UFH therapeutic range was determined using 3 previously described methods: calibration of the aPTT to 0.3 to 0.7 U/mL anti-Xa activity, application of 1.5 to 2.5 times the control aPTT, or using 0.3 to 0.7 U/mL anti-Xa activity directly. We also applied the UFH therapeutic range of a second hospital to our patient population.

Results

Application of the guideline-prescribed anti-Xa calibration method would result in patients receiving increased UFH dosage in comparison to our previous UFH nomogram. Between-method and between-laboratory variations in aPTT and anti-Xa activity assays are a likely cause of these discrepancies. Additionally, we show that individual patient characteristics, such as weight and UFH treatment duration, likely contribute to the discordance between different strategies to establish an UFH therapeutic range.

Conclusion

No consensus is reached between different strategies to define the UFH therapeutic range, which could result in relevant differences in UFH doses applied in patients. Clinicians and laboratory specialists should critically evaluate UFH monitoring protocols and be aware of their shortcomings.

SUBMITTER: Coene KLM

PROVIDER: S-EPMC6714639 | biostudies-literature | 2018 Jan

REPOSITORIES: biostudies-literature

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Publications

Protocolled Redefinition of the Therapeutic Range for Unfractionated Heparin: Lost in Translation?

Coene Karlien L M KLM van der Graaf Fedde F van de Kerkhof Daan D

Clinical and applied thrombosis/hemostasis : official journal of the International Academy of Clinical and Applied Thrombosis/Hemostasis 20161116 1

<h4>Background</h4>Protocolled treatment with unfractionated heparin (UFH) is a subject of ongoing debate. Even though international guidelines prescribe calibration of the activated partial thromboplastin time (aPTT) to 0.3 to 0.7 U/mL anti-Xa activity to establish an UFH therapeutic range, evidence for this approach remains scarce. In this study, we evaluated different strategies to delineate the UFH therapeutic range and analyzed the effects on patient therapeutic classification.<h4>Methods</ ...[more]

PMID: 27856667

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Project description:BackgroundPatients hospitalized with severe acute respiratory syndrome coronavirus 2 infection are at risk for thrombotic complications necessitating use of therapeutic unfractionated heparin (UFH). Full-dose anticoagulation limits requirements for organ support interventions in moderately ill patients with coronavirus disease 2019 (COVID-19). Given this benefit, it is important to evaluate response to therapeutic anticoagulation in this population.ObjectivesThe aim of this study was to assess therapeutic UFH infusions and associated bleeding risk in patients with COVID-19.Patients/methodsThis retrospective cohort study includes patients at Brigham and Women's Hospital, Boston, Massachusetts, receiving weight-based nursing-nomogram titrated UFH infusion during a 10-week surge in COVID-19 hospitalizations. Of 358 patients on therapeutic UFH during this interval, 97 (27.1%) had confirmed COVID-19. Patient characteristics, laboratory values, and information regarding UFH infusion and bleeding events were obtained from the electronic medical record.ResultsPatients who were COVID-19 positive had fewer therapeutic activatrd partial thromboplastin times (aPTTs) compared to COVID-19-negative patients (median rate, 40.0% vs 53.1%; P < .0005). Both major and clinically relevant nonmajor bleeding were increased in COVID-19-positive patients, with major bleeding observed in 10.3% (95% confidence interval [CI], 5.7%-17.9%) of patients who were COVID-19 positive and 3.1% (95% CI, 1.6%-5.9%) of patients who were COVID-19 negative (P < .005). In logistic regression, bleeding events were associated with receiving UFH for longer than 7 days, but not platelet count, coagulation, or inflammatory measurements.ConclusionsOur data indicate a higher incidence of bleeding complications in patients with COVID-19 receiving weight-based nursing-nomogram titrated UFH infusions despite a higher prevalence of subtherapeutic aPTTs in this population. These data underscore the need for prospective studies aimed at improving the quality and safety of therapeutic anticoagulation in patients with COVID-19.

Project description:BackgroundLow molecular weight heparins (LMWH) have been extensively studied and became the treatment of choice for several indications including pulmonary embolism. While their efficacy in hemodialysis is considered similar to unfractionated heparin (UFH), their safety remains controversial mainly due to a risk of bioaccumulation in patients with renal impairment. The aim of this systematic review was to evaluate the safety of LMWH when compared to UFH for extracorporeal circuit (ECC) anticoagulation.MethodsWe used Pubmed, Embase, Cochrane central register of controlled trials, Trip database and NICE to retrieve relevant studies with no language restriction. We looked for controlled experimental trials comparing LMWH to UFH for ECC anticoagulation among end-stage renal disease patients undergoing chronic hemodialysis. Studies were kept if they reported at least one of the following outcomes: bleeding, lipid profile, cardiovascular events, osteoporosis or heparin-induced thrombocytopenia. Two independent reviewers conducted studies selection, quality assessment and data extraction with discrepancies solved by a third reviewer. Relative risk and 95% CI was calculated for dichotomous outcomes and mean weighted difference (MWD) with 95% CI was used to pool continuous variables.ResultsSeventeen studies were selected as part of the systematic. The relative risk for total bleeding was 0.76 (95% CI 0.26-2.22). The WMD calculated for total cholesterol was -28.70 mg/dl (95% CI -51.43 to -5.98), a WMD for triglycerides of -55.57 mg/dl (95% CI -94.49 to -16.66) was estimated, and finally LDL-cholesterol had a WMD of -14.88 mg/dl (95% CI -36.27 to 6.51).ConclusionsLMWH showed to be at least as safe as UFH for ECC anticoagulation in chronic hemodialysis. The limited number of studies reporting on osteoporosis and HIT does not allow any conclusion for these outcomes. Larger studies are needed to evaluate properly the safety of LMWH in chronic hemodialysis.

Dataset Information

Protocolled Redefinition of the Therapeutic Range for Unfractionated Heparin: Lost in Translation?

Background

Methods

Results

Conclusion

Publications

Protocolled Redefinition of the Therapeutic Range for Unfractionated Heparin: Lost in Translation?

Similar Datasets

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