Abstract
Intravenous unfractionated heparin (UFH) remains one of the most commonly used anticoagulants in the hospital setting. The optimal protocol for initiation and maintenance of UFH has been difficult to determine. Over the past two decades, weight-based nomogram protocols have gained favor. Herein, we present a retrospective study of 377 patients at a single tertiary academic center treated with low intensity (LI) and standard intensity (SI) UFH protocols for therapeutic anticoagulation. UFH levels are measured by anti-Xa assay activity with therapeutic levels of 0.30 to 0.70 IU/mL for SI and 0.25 to 0.35 IU/mL for LI. Patients treated on the LI protocol were more likely to have had a previous history of bleeding and lower baseline hemoglobin. Incidence of new or worsening thrombus while on UFH was comparable between both protocols (odds ratio (OR) 0.93, 95% confidence interval (CI) 0.29-2.98, p=0.899). Patients on LI protocol had higher incidence of bleeding while on UFH (OR 1.21, 95% CI 0.51-2.89, p=0.667). Our study thus suggests that the LI protocol may have comparable efficacy to the SI protocol in treating venous thromboembolism (VTE) and that target anti-Xa levels of 0.25 to 0.35 IU/mL may be more optimal in high-risk patients.
Highlights
Since the discovery of heparin by Howell in 1916 and its initial use on human subjects in 1935, it has been one of the most commonly utilized inpatient medications in modern medicine [1,2]
Given the importance of the use of therapeutic heparin in treating venous thromboembolism (VTE) and minimizing the risk of hemorrhage posed by its use, determining the optimal protocol is of the utmost importance
The 2012 American College of Chest Physicians (ACCP) guidelines published as the 9th edition in Chest recommend an initial bolus of 80-units/kg followed by 18 units/kg/hr adjusted to therapeutic levels [13]
Summary
Since the discovery of heparin by Howell in 1916 and its initial use on human subjects in 1935, it has been one of the most commonly utilized inpatient medications in modern medicine [1,2]. Despite its frequent inpatient use and importance in preventing and treating venous thromboembolism (VTE), therapeutic protocols for unfractionated heparin (UFH) have varied between institutions and organizations. Given the importance of the use of therapeutic heparin in treating VTE and minimizing the risk of hemorrhage posed by its use, determining the optimal protocol is of the utmost importance. Determining the optimal protocol for UFH bolus and subsequent infusion has been controversial. In 1989, the American College of Chest Physicians (ACCP) Clinic Practice Guideline on VTE treatment recommended an initial bolus of 5,000-units followed by 1000-units/hour [3]. The 2012 ACCP guidelines published as the 9th edition in Chest recommend an initial bolus of 80-units/kg followed by 18 units/kg/hr adjusted to therapeutic levels [13]
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