Appropriateness of the Initial Dose of Enoxaparin and the Occurrence of Major Bleeding in Patients with Non-ST-segment Elevation Acute Coronary Syndromes

Article Sidebar

pdf
Published: Sep 14, 2023
Keywords:
enoxaparin acute coronary syndromes bleeding non-ST-segment elevation acute coronary syndromes non ST-elevation myocardial infarction

Main Article Content

Sinwisuth Sutheechai
Pharmaceutical Care Training Center (PCTC), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University
Chakorn Lertwiriyasathira
Department of Pharmacy, Rajavithi Hospital, Bangkok
Chonlathorn Witsaket
Klang-Ya-Sri-Chum Community Pharmacy, Muang District, Lampang
Mantiwee Nimworapan
Pharmaceutical Care Training Center (PCTC), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University; 4Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University

Abstract

Objective: To study the appropriateness of the initial dose of enoxaparin and the occurrence of major bleeding in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS). Methods: A retrospective study was conducted on patients receiving enoxaparin for NSTEACS treatment between January 1, 2014 and June 30, 2017 at Maharaj Nakorn Chiang Mai Hospital. The study determined the appropriateness of the initial dose of enoxaparin defined as being different from the recommended dose not more than 10 mg/day or not more than 10%. The major bleeding events according to the Bleeding Academic Research Consortium (BARC) type 3a-c and type 5 within 30 days were follow-ups. Results: Of the 255 patients, 200 were diagnosed with the non ST-elevation myocardial infarction (NSTEMI) and 55 were unstable angina. The patients were 63.8 ± 12.2 years old, 151 males with mean body weight of 58 ± 13.4 kg and mean eGFR of 69.97 ± 24.03 ml/min/1.73 m2. Mean of enoxaparin dose per body weight was 0.88 ± 0.17 mg/kg. Ninety-six (36.1%) patients received an appropriate initial dose of enoxaparin with a difference of no more than 10 mg/day from the recommended dose, while 80 cases (31.4%) received the initial dose with a difference of no more than 10% from the recommended dose. Major bleeding was found in 11 patients (4.3%). Multivariate logistic regression analysis found that age 75 years and over was a risk factor for major bleeding (aOR=5.47, 95%CI: 1.41 - 21.16, P=0.01). Conclusion: Most NSTEACS patients received inappropriate doses of enoxaparin. Enoxaparin prescribing should be based on actual weight. Major bleeding should be monitored in elderly patients.

Article Details

Issue
Vol. 15 No. 4 (2023): Oct-Dec
Section
Research Articles
Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

        ผลการวิจัยและความคิดเห็นที่ปรากฏในบทความถือเป็นความคิดเห็นและอยู่ในความรับผิดชอบของผู้นิพนธ์ มิใช่ความเห็นหรือความรับผิดชอบของกองบรรณาธิการ หรือคณะเภสัชศาสตร์ มหาวิทยาลัยสงขลานครินทร์ ทั้งนี้ไม่รวมความผิดพลาดอันเกิดจากการพิมพ์  บทความที่ได้รับการเผยแพร่โดยวารสารเภสัชกรรมไทยถือเป็นสิทธิ์ของวารสารฯ 

References

The Heart Association of Thailand. Thai acute coronary syndromes guideline 2020. Bangkok: Nextstep d-sign; 2020.

Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42: 1289–367.

Jinatongthai P, Khaisombut N, Likittanasombat K, Chaiyakunapruk N, Watcharathanakij S, Nathisuwan S. Use of the CRUSADE bleeding risk score in the prediction of major bleeding for patients with acute coronary syndrome receiving enoxaparin in Thailand . Heart Lung Circ. 2014; 23: 1051–8.

Macie C, Forbes L, Foster GA, Douketis JD. Dosing practices and risk factors for bleeding in patients receiving enoxaparin for the treatment of an acute coronary syndrome. Chest. 2004; 125: 1616–21.

LaPointe NMA, Chen AY, Alexander KP, Roe MT, Pollack CV, Lytle BL, et al. Enoxaparin dosing and associated risk of in-hospital bleeding and death in patients with non ST-segment elevation acute coronary syndromes. Arch Intern Med. 2007; 167: 1539–44.

Spinler SA, Inverso SM, Cohen M, Goodman SG, Stringer KA, Antman EM, et al. Safety and efficacy of unfractionated heparin versus enoxaparin in patients who are obese and patients with severe renal impairment: analysis from the ESSENCE and TIMI 11B studies. Am Heart J. 2003; 146: 33–41.

Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2014; 64: e139–228.

Kiatchoosakun S, Wongvipaporn C, Buakhamsri A, Sanguanwong S, Moleerergpoom W, Sarakarn P, et al. Predictors of in-hospital mortality in non-ST elevation acute coronary syndrome in Thai Acute Coronary Syndrome Registry (TACSR). J Med Assoc Thai. 2007; 90 Suppl 1: 41–50.

Cavender MA, Rao SV, Ohman EM. Major bleeding: management and risk reduction in acute coronary syndromes. Expert Opin Pharmacother. 2008; 9: 1869–83.

Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation 2011; 123: 2736–47.

Spinler SA, Dobesh P. Dose capping enoxaparin is unjustified and denies patients with acute coronary syndromes a potentially effective treatment. Chest 2005; 127: 2288–9.

Enoxaparin. In: Lexi-drugs online [database on the Internet]. Hudson (OH): Lexicomp, Inc.; 2022 [updated 11 Apr 2022; cited 14 Nov 2022]. Available from: http://online.lexi.com. Subscription required to view.

Enoxaparin. In: Clinical Pharmacology [database on the Internet]. Tampa (FL): Elsevier; 2022 [cited 2022 Nov 14]. Available from: www.clinicalpharmacology .com. Subscription required to view.

Wayne WD. Biostatistics: A foundation of analysis in the health sciences. 6th ed. Atlanta, GA: John Wiley & Sons; 1995; p. 180.

Xu Y, Gomes T, Wells PS, Pequeno P, Johnson A, Sholzberg M. Evaluation of definitions for oral anticoagulant-associated major bleeding: A popula- tion-based cohort study. Thromb Res. 2022; 213: 57–64.

Chua D, Tataru A. Enoxaparin dosing for acute coronary syndromes in obese patients-should there be a maximum dose? J Cardio Cardiovasu Med 2016; 1: 1-4.

Spinler SA, Ou FS, Roe MT, Gibler WB, Ohman EM, Pollack CV, et al. Weight-based dosing of enoxaparin in obese patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE initiative. Pharmacotherapy. 2009; 29: 631–8.

Inker LA, Eneanya ND, Coresh J, Tighiouart H, Wang D, Sang Y, et al. New creatinine- and cystatin C-based equations to estimate GFR without race. N Engl J Med. 2021; 385: 1737–49.

Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976; 16: 31–41.

Henderson MC, White RH. Anticoagulation in the elderly. Curr Opin Pulm Med. 2001; 5: 365–70.

Cinch D, Banerjee AK, Ostick G. Absence of abdominal pain in elderly patients with peptic ulcer. Age Ageing. 1984; 13: 120–3.

Cadroy Y, Pourrat J, Baladre MF, Saivin S, Houin G, Montastruc JL, et al. Delayed elimination of enoxaparin in patients with chronic renal insufficiency. Thromb Res. 1991; 63: 385–90.

Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, et al. Management of acute coronary syndrome in the older adult population: a scientific statement from the American Heart Association. Circulation. 2023; 147: e32-62.

Ibbotson T, Goa KL. Enoxaparin: an update of its clinical use in the management of acute coronary syndromes. Drugs. 2002; 62: 1407–30.