Dose Of Low Molecular Weight Heparin Research Articles

Outcomes of Open Surgery for Retroperitoneal Hematoma in Covid-19 Patients: Experience from a Single Centre.

Background: Spontaneous retroperitoneal hematoma is a severe and potentially fatal complication that appears in the course of anticoagulation therapy. Therapeutic doses of low molecular weight heparin (LMWH) are used for the prevention of thrombosis in patients seriously ill with Covid-19. Methods: We describe 27 (0.14%) patients with retroperitoneal hematomas who required emergency surgery out of 19108 patients with Covid-19 who were hospitalized in Batajnica COVID Hospital between March 2021 and March 2022. All the patients were on therapeutic doses of LMWH. The existence of retroperitoneal hematoma was confirmed by abdominal ultrasound and computed tomography scans. Results: Open surgery was performed on 27 patients with spontaneous retroperitoneal hematomas (12 female and 15 male). The mean age of the study population was 71.6+-11.9 years. D-dimer was significantly elevated two days before the surgery in comparison with the values on the day of surgery (p=0.011). Six patients (22.23%) survived, while 21 (77.77%) patients died. Conclusion: Bleeding in Covid-19 patients treated by LMWH is associated with an increased risk of developing retroperitoneal hematoma. Open surgery for retroperitoneal hematoma in Covid-19 patients on anticoagulation therapy is a procedure associated with a high rate of mortality.

Comparison of doses of heparin for venous thromboembolism and bleeding in pregnant women

The evaluation criteria for dosage of low-molecular-weight heparin (LMWH) for pregnant women at high risk of venous thromboembolism (VTE) remain unclear. A retrospective study was performed to investigate the relative...

C36. Deep Vein Thrombosis in A Patient with Thrombocytopenia : Case Report

Abstract Background Deep vein thrombosis (DVT) is a common but elusive illness that can result in suffering and death if not recognized and treated effectively. Overall, 43% of patients with thrombocytopenia were hospitalized, but just 2% of patients had DVT. Case Summary A 48-year-old male patient presented with a complaint left leg pain accompanied by edema leg 8 days before admission. The patient is a smoker, the patient has a history of diabetes since one year ago, In the laboratory results showed platelet count 23,000/mm3, D-dimer above 4000 ng/ml. Anti-dengue IgM and IgG were negative. Doppler examination revealed a thrombus in the common femoral and popliteal veins of the left leg. Patient was treated with low molecular weight heparin (LMWH) Subcutan fondaparinux 5 mg once daily for up to 7 days without bleeding and continued with Rivaroxaban 20 mg once daily, The patient was discharged on day 14. Discussion Platelet count below 50 x109/L significantly reduces the risk of DVT. Some known risk factors for DVT still appear to apply in patients with thrombocytopenia, and therefore patients with thrombocytopenia would benefit from DVT risk stratification based on platelet count and comorbidity. Patients having thrombocytopenia with DVT were treated safely with anticoagulants without increased occurrence of bleeding. The majority of cases were given therapeutic doses of LMWH.

C36. Deep Vein Thrombosis in A Patient with Thrombocytopenia : Case Report

Abstract Background Deep vein thrombosis (DVT) is a common but elusive illness that can result in suffering and death if not recognized and treated effectively. Overall, 43% of patients with thrombocytopenia were hospitalized, but just 2% of patients had DVT. Case Summary A 48-year-old male patient presented with a complaint left leg pain accompanied by edema leg 8 days before admission. The patient is a smoker, the patient has a history of diabetes since one year ago, In the laboratory results showed platelet count 23,000/mm3, D-dimer above 4000 ng/ml. Anti-dengue IgM and IgG were negative. Doppler examination revealed a thrombus in the common femoral and popliteal veins of the left leg. Patient was treated with low molecular weight heparin (LMWH) Subcutan fondaparinux 5 mg once daily for up to 7 days without bleeding and continued with Rivaroxaban 20 mg once daily, The patient was discharged on day 14. Discussion Platelet count below 50 x109/L significantly reduces the risk of DVT. Some known risk factors for DVT still appear to apply in patients with thrombocytopenia, and therefore patients with thrombocytopenia would benefit from DVT risk stratification based on platelet count and comorbidity. Patients having thrombocytopenia with DVT were treated safely with anticoagulants without increased occurrence of bleeding. The majority of cases were given therapeutic doses of LMWH.

Risk of Recurrent Venous Thromboembolism and Hemorrhage Following Interruption of Anticoagulation at Delivery

Background: Current guidelines for regional anesthesia advise for the discontinuation of prophylactic and therapeutic low molecular weight heparin (LMWH) 12 hours and 24 hours, respectively prior to the use of neuraxial anesthesia (NA) for obstetric patients. Re initiating a prophylactic dose 12 hours following epidural catheter insertion/spinal anesthesia (SA) and at least 4 hours following epidural catheter removal is also recommended. There are limited data on the recurrent risk of venous thromboembolism (VTE) and bleeding using these standards. We conducted a retrospective single center study to assess the risk of VTE and/or bleeding in pregnant women using these criteria.Methods: Consecutive patients from 2013 to 2018 at Mount Sinai Hospital, a university affiliated tertiary care center in Toronto, Canada who were prescribed therapeutic or prophylactic LMWH antenatally and postpartum and who had NA were included. Hospital records were reviewed to determine the indication and dosage of LMWH, presence of thrombophilia, time of first LMWH injection postpartum, the mode of neuraxial anesthesia and delivery, the time of epidural catheter/spinal anesthesia, the time of epidural catheter removal, laboratory parameters and comorbid illnesses. Patients requiring therapeutic or prophylactic LMWH were assessed in the Hematology clinic and were advised to discontinue anticoagulation according to current recommendations. The primary outcomes were frequency of VTE, spinal hematoma and volume of postpartum blood loss. Statistical Analysis: Continuous variables were summarized as medians and interquartile ranges. Categorical variables were summarized as percentages. Characteristics associated with VTE and hemorrhage were analyzed using regression analysis.Results: Of 169 pregnancies, 158 fulfilled criteria, and 110 had complete data for the time of epidural catheter removal and initiation of LMWH. Median age was 34 (IQR 5) years and median weight 90 (IQR 70) kgs. Diagnoses included antiphospholipid syndrome, Budd Chiari, provoked and unprovoked VTE. Median platelet count at delivery was 185 (IQR 76) x 10(9)/L. Thirty-three percent were using concomitant ASA antenatally. Forty-four percent (n=48) had a vaginal delivery (VD). Sixty five (59%) had epidural anesthesia, 43 (39%) had SA and, two had combined spinal/epidural anesthesia. Median time to restarting LMWH was 7.8 (IQR 4.7) hours from epidural catheter removal/spinal insertion and 9 (IQR 3.9) hours from SA. There were no spinal hematomas. Median blood loss was 500 (IQR 400) ml. One patient, who received prophylactic dose LMWH antepartum, had a Caesarean delivery, spinal anesthesia and a prophylactic dose re-started 13.7 hours after SA, developed a delayed postpartum hemorrhage. One patient developed a VTE (1%). She developed a distal and superficial thrombus immediately after delivery. She was using antenatal prophylactic LMWH as she had an unprovoked VTE predating pregnancy, was heterozygous for the prothrombin gene mutation, had epidural anesthesia and VD. She received prophylactic LMWH three hours after catheter removal which was also 10 hours after catheter insertion.Limitations: Time of discontinuation of LMWH prior to induction could not be confirmed definitively as this was a retrospective review.Conclusion: Prospective studies are required to confirm these findings and to determine the safety of current recommendations of interrupting anticoagulation prior to regional anesthesia and delivery and to identify risk factors for hemorrhage and recurrent VTE to optimize anticoagulation regimens for these patients. DisclosuresMalinowski: Alexion: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy.

Management and Outcomes of Women with Antiphospholipid Antibodies or Antiphospholipid Syndrome during Pregnancy

BackgroundPregnant women with antiphospholipid antibodies (aPLs) or antiphospholipid syndrome have an increased risk for thrombosis. Although a combination of low-dose aspirin and unfractionated heparin (UFH) or low molecular weight heparin (LMWH) are usually prescribed in pregnancy, there is no consensus on optimal dosing of these agents. Despite the use of low-dose aspirin and LMWH, approximately 30% of women with a positive lupus anticoagulant (LA), underlying autoimmune disease, or a previous history of thrombosis have unfavorable outcomes.AimTo describe the management and outcomes of women with either aPLs or APS during pregnancy at a university medical center.MethodsWe conducted a retrospective cohort study of pregnant women with either aPLs or APS seen in our hematology clinic in consultation between January 2006 and August 2021. Data collected included demographics, reason for aPLs testing, personal or family history of thrombosis or autoimmune disease, and presence of other thrombophilias. Antiphospholipid antibodies included the LA, anti-cardiolipin (aCL) and anti-beta-2 glycoprotein 1 (ß2GP1) confirmed on two occasions at least 12 weeks apart. Data was collected on antithrombotic agents used during pregnancy, including aspirin, dose of LMWH, UFH and certolizumab. We recorded the following obstetric outcomes: live births, early delivery, fetal loss, early pregnancy loss <10 weeks gestational age (GA), pre-eclampsia, venous thromboembolic events (VTE), arterial thromboembolism (ATE), and post-partum hemorrhage (PPH). We compared management and outcomes in the presence or absence of LA. Statistical comparisons between groups were conducted with the Fisher's exact test.ResultsThere was a total of 202 pregnancies in 62 women with 11% of pregnancies achieved with assisted reproductive techniques. The most common reasons for aPLs testing were pregnancy loss (35%), VTE (23%), and ATE (8%). Antiphospholipid antibody profiles consisted of 56% triple positive, 8% positive LA plus either aCL or anti- ß2GP1, 13% positive LA alone and 22% with either double positive aCL and anti- ß2GP1 or single aCL or anti- ß2GP1. Twenty-tree percent of women had an additional inherited thrombophilia (Table 1). Of the 202 pregnancies, 52% resulted in live births, 20% in pregnancy loss <10 weeks, 12% in pregnancy loss >10 weeks, and 28% were either electively terminated, resulted on an ectopic pregnancy, or the outcome was unknown due to lost to follow up. Antithrombotic therapy was used in 47% of pregnancies: 26% used aspirin and LMWH, 10% used LMWH alone, and 7% used aspirin alone (Table 2). In 10% of pregnancies, patients were transitioned to UFH prior to delivery. Pre-eclampsia with or without HELLP syndrome occurred in 10% of pregnancies and maternal thromboembolic complications occurred in 6%. On analysis of outcomes stratified by LA status, there was a trend toward a higher rate of preterm births in the presence of a positive LA (Table 3). The rate of live births was increased with the use of antithrombotic therapy (Table 4).ConclusionPatients with antiphospholipid antibodies (aPLs) and antiphospholipid syndrome had elevated rates of complications and adverse outcomes during pregnancy. LA positive status was associated with a trend toward a higher rate of preterm births. Further studies are needed to clarify the factors associated with adverse outcomes and optimal anticoagulation management. [Display omitted] DisclosuresDesancho: Sanofi-Genzyme: Membership on an entity's Board of Directors or advisory committees. OffLabel Disclosure:Certolizumab with the hypothesis of improving clinical outocomes

Prophylaxis and management of venous thromboembolism during pregnancy and postpartum period

Introduction. Venous thromboembolism (VTE) is one of the lead causes for maternal mortality and morbidity during pregnancy in the majority of developed countries. The incidence rate of VTE per pregnancy-year increases during pregnancy and postpartum period about by 4-fold and at least 14-fold, respectively.Aim: to analyze and summarize current view on risk factors of thrombotic events during gestation and to discuss recent guidelines for the management of venous thromboembolic complications during pregnancy and postpartum, by taking into account a balance between risks and benefits of using anticoagulants.Materials and Methods. The literature search covering the last 10 years was carried out in the electronic scientific databases RSCI, PubMed/MEDLINE, and Embase. While formulating a search strategy for evidence-based information, the PICO method (P = Patient; I = Intervention; C = Comparison; O = Outcome) and the key terms “venous thromboembolism” and “pregnancy” were used.Results. Risk factors were found to include a personal history of VTE, verified inherited or acquired thrombophilia, a family history of VTE and general medical conditions, such as immobilization, overweight, varicose veins, some hematological diseases and autoimmune disorders. VTE is considered being potentially preventable upon prophylactic administration of anticoagulants, but no high confidence randomized clinical trials comparing diverse strategies of thromboprophylaxis in pregnant women have been proposed so far. Because heparins do not cross the placenta, weight-adjusted therapeutic-dose low molecular weight heparins (LMWH) represent the anticoagulant treatment of choice for VTE during pregnancy. Once- and twice-daily dosing regimens are acceptable. However, no evidence suggesting benefits for measurement of factor Xa activities and consecutive LMWH dose adjustments to improve clinical outcomes are available. In case of uncomplicated pregnancy-related VTE, no routine administration of vitamin K antagonists, direct thrombin or factor Xa inhibitors, fondaparinux, or danaparoid is recommended. Lactating women may switch from applying LMWH to warfarin. Anticoagulation therapy should be continued for 6 weeks postpartum with total duration lasting at least for 3 months.Conclusion. VTE is a challenging task in pregnant women expecting to apply a multi-faceted approach for its efficient solution by taking into account updated recommendations and personalized patient-oriented features.

Prevalence of Deep Vein Thrombosis in Cancer Patients in Hospitals of Rawalpindi

Background and Aim: Carcinoma/Cancer patients are more susceptible to venous thromboembolism compared to common disease patients. Regardless of chemotherapy, venous thromboembolism risk increases by 5-6 fold. The aim of the present study was to evaluate the prevalence of deep vein thrombosis in Fauji Foundation, Holy Family and Benazir Bhutto Hospital of Rawalpindi. Materials and Methods: This cross-sectional study was carried out on 434 carcinoma/cancer patients presented to the Department of Medical Oncology, Fauji Foundation, Holy Family and Benazir Bhutto Hospital of Rawalpindi from May 2020 to July 2021. Malignancy patients of age range from 5 years to 65 years with deep vein thrombosis clinical signs and symptoms were investigated. All patients had to have a biopsy to prove they had cancer. All patients underwent routine baseline investigations, which included a complete blood picture ECG, biochemistry, and X-rays. Results: Of the total 434 carcinoma/cancer patients, 23 (5.3%) malignant patients had deep vein thrombosis. The overall mean age of 23 patients was 34.56 ± 8.71 years with an age range from 5 years to 65 years. Out of 23 patients, 14 (60.9%) were male and 9 (39.1%) were females. The prevalence of primary cancer (tumors) and hematological malignancies were 11 (47.8%) and 12 (52.2%) respectively. Enoxaparin injections of 1mg/kg/day were prescribed to these patients for 5 days to 7 days duration followed by 6 months of warfarin. Conclusion: Our study found that the prevalence of deep vein thrombosis was 5.3%. Antithrombotic agents lower the risk of venous thromboembolism in cancer patients undergoing chemotherapy. Low dose warfarin and Low molecular weight heparins can both prevent and treat cancer-related thrombosis. Venous thromboembolism be treated with either unfractionated heparin (UFH) or low molecular weight heparin (LMWH) before starting Warfarin therapy as per guidelines. Keywords: Prevalence, Deep vein thrombosis, Warfarin

Philadelphia-Negative Myeloproliferative Neoplasms Around the COVID-19 Pandemic.

Purpose of ReviewCoronavirus disease 2019 (COVID-19) is associated with a high rate of respiratory failure, thromboembolism, bleeding, and death. Patients with myeloproliferative neoplasms (MPNs) are prone to both thrombosis and bleeding, calling for special care during COVID-19. We reviewed the clinical features of MPN patients with COVID-19, suggesting guidance for treatment.Recent FindingsOne study by the European LeukemiaNet collected 175 MPN patients with COVID-19 during the first wave of the pandemic, from February to May 2020. Patients with primary myelofibrosis (PMF) were at higher risk of mortality (48%) in comparison with essential thrombocythemia (ET) (25%) and polycythemia vera (19%); the risk of death was higher in those patients who abruptly discontinued ruxolitinib. In patients followed at home, in regular wards, or in ICU, the thrombosis rate was 1.0%, 2.8%, and 18.4%, respectively. Independent risk factors for thrombosis were ET phenotype, transfer to ICU, and neutrophil/lymphocyte ratio; major bleeding occurred in 4.3% of patients, particularly those with PMF.SummaryMPN patients with non-severe COVID-19 treated at home should continue their primary or secondary antithrombotic prophylaxis with aspirin or oral anticoagulants. In the case of hospitalization, patients assuming aspirin should add low molecular weight heparin (LMWH) at standard doses. In contrast, LMWH at intermediate/therapeutic doses should replace oral anticoagulants prescribed for atrial fibrillation or previous venous thromboembolism. Intermediate/high doses of LMWH can also be considered in ICU patients with ET, particularly in the case of a rapid decline in the number of platelets and progressive respiratory failure.

Approach to the Evaluation and Treatment of Venous Thromboembolism in Pregnancy.

Thrombosis in pregnancy is a major cause of maternal and fetal morbidity and mortality. Risk stratification of venous thromboembolism (VTE) during pregnancy is complex. The hypercoagulability observed in pregnant women can reduce bleeding during childbirth, but may cause thrombosis especially in the presence of additional prothrombotic risk factors such as antiphospholipid antibodies or genetic thrombophilic defects. The availability of large datasets allows for the identification of additional independent risk factors, including assisted reproductive technologies (ARTs), endometriosis, and recurrent pregnancy loss. Data on the risk of VTE linked to COVID-19 in pregnant women are very limited, but suggest that infected pregnant women have an increased risk of VTE. Current guidelines on the prevention and treatment of VTE in pregnancy are based on available, albeit limited, data and mainly present expert opinion. Low-molecular-weight heparins (LMWHs) are the mainstay of anticoagulation to be employed during pregnancy. Administration of LMWH for VTE treatment in pregnancy should be based on the personalized approach, taking into account a weight-based adjusted scheme. During gestation, due to physiological changes, in women at high risk of VTE, monitoring of anti-Xa activity is performed to ensure adequate LMWH dosing. As for the treatment duration for pregnant women with acute VTE, guidelines suggest that anticoagulation should be continued for at least 6 weeks postpartum for a minimum total duration of therapy of 3 months.

Potential benefits of anticoagulant doses of low molecular weight heparin in COVID-19: An observational retrospective study

Hypercoagulability is a common complication of the systemic inflammation related to coronavirus disease 2019 creating debate within the critical care community on the therapeutic utility of Low Molecular Weight Heparin (LMWH). We collected data on consecutive patients with COVID-19 admitted to the Emergency Department of Castel San Giovanni Hospital, between February 29th and April 7th, 2020. Exclusion criteria were age &lt;18 years, hospital stay &lt;7 days, patients on dialysis and patients who had been transferred to other centers for which we could not collect data. Of the 257 patients included in the study, 49 (19.1%) died during hospitalization. We considered a wide set of variables as independent variables (age, sex, comorbidities and in-hospital treatments). We used a multivariate logistic regression model and, being heparin the only one therapy affecting survival rate, we compared prophylactic LMWH (p-LMWH) and Therapeutic LMWH (T-LMWH) groups. Kaplan Meier curve showed a higher survival probability in the T-LMWH and the difference between the two groups was statistically significant according to the log-rank or Mantel- Haenszel test (p&lt; 0.0001). In a stratified analysis by ventilation type, the subgroup of patients who benefited from therapeutic LMWH was that in non-invasive mechanical ventilation. Using a multivariate analysis and adjusting for the drugs intake, TLMWH was the only therapy impacting on survival (HR 0.293, p &lt;0.001). No fatal bleeding was observed. Therapeutic dose of LMWH in patients admitted to hospital with COVID-19 pneumonia was 70 associated with a decrease risk of intra-hospital mortality.

Anticoagulant treatment of venous thromboembolism in pregnant women

Venous thromboembolism (VTE), in particular pulmonary embolism (PE), remains the leading cause of death among pregnant women. Low-molecular-weight heparin (LMWH), with preference for therapeutic doses given twice daily according to European guidelines, is the drug of choice for the treatment of VTE in pregnancy and the puerperium. The recommended therapeutic dose is calculated on early pregnancy body weight. Evidence to support anti-Xa monitoring in pregnancy is weak. Unfractionated heparin (UFH) with multiple activated partial thromboplastin time measurements is still used in the acute treatment of high-risk PE. American experts have suggested considering initial outpatient therapy over hospital admission also in pregnant women with low-risk acute VTE, but European experts suggest adopting such a strategy selectively, for example in isolated distal leg thrombosis. Scheduled delivery with prior discontinuation of anticoagulant therapy in pregnant women who received a therapeutic dose of LMWH is suggested with the restart of therapy 4–6 h after a vaginal birth and 6–12 h after a cesarean delivery. It is recommended that UFH, LMWH, warfarin, acenocoumarol, or fondaparinux, but not direct-acting oral anticoagulants, should be used in breastfeeding women. This review summarizes the key messages from current guidelines mainly based on low-quality evidence and expert consensus.

Acute myocardial infarction and arterial embolism in a patient with newly diagnosed renal mass: management dilemmas! A case report

BackgroundCancer is often associated with a hypercoagulable state and new thrombosis is often the first clinical manifestation of cancer. Surgical treatment of the primary tumor is crucial since it provides the only curative approach in most cases, but management of patients is highly complex, especially in the presence of new antiplatelet drugs and/or anticoagulants. Paraneoplastic syndromes (PNS) represent a frequent complication of renal cell carcinomas (RCC) and include different hematological symptoms in patients, whilst occlusion of arterial blood vessels displays a rare form of PNS accompanying renal tumors.Case presentationWe report the case of a 62-year old man who was initially hospitalized due to acute coronary syndrome. He subsequently underwent coronary angioplasty treatment including multiple stenting and treatment with ticagrelor and aspirin. Post-interventional, acute arterial thrombotic emboli of several limb arteries required thrombectomy. By computer tomography we identified a renal lesion suspicious for an RCC and suspected a PNS as underlying cause of the thrombotic complications. Triple anticoagulant therapy was maintained with therapeutic dose low molecular weight heparin (LMWH), aspirin, and clopidogrel, by which we replaced ticagrelor. Surgery was postponed for 4 weeks. We paused LMWH, aspirin and clopidogrel only at the day of surgery and perioperatively restored hemostasis by transfusion of two platelet concentrates. Laparoscopic nephrectomy was uneventful. Pathology confirmed a clear cell RCC. The patient fully recovered whilst slowly reducing anticoagulation dose.ConclusionsA multidisciplinary team approach of experts in urology, cardiology and hemostasis was key in managing this patient since a personalized thrombosis consult was needed to minimize the risk of reinfarction due to in-stent thrombosis. We report a therapeutic protocol that may be helpful for the management of similar cases. Furthermore, the finding of thrombotic arterial occlusions in larger blood vessels represents a novel complication of PNS in RCC and adds to the varied possible manifestations of this clinical chameleon.

Perioperative management of post-COVID-19 surgical patients: Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement.

Perioperative management of post-COVID-19 surgical patients: Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement.

Abstracts of the 30th Annual Pediatric Pharmacy Association (PPA) Meeting April 21 to 25, 2021

Abstracts of the 30th Annual Pediatric Pharmacy Association (PPA) Meeting April 21 to 25, 2021

Treatment of Venous Thromboembolism in Acute Leukemia: A Systematic Review

Background: Patients with hematologic malignancies are up to 26 times more likely to develop venous thromboembolism (VTE) than the general population. The standard treatment for VTE is anticoagulation, however, it's safety and efficacy in this patient population has not been formally evaluated. In addition, severe thrombocytopenia and coagulopathies in patients with hematologic malignancies makes treatment of VTE challenging and the optimal treatment strategy for VTE in this patient population is unclear.Methods: We conducted a systematic review of the literature aiming to identify observational studies and randomized trials describing treatment of VTE in the setting of acute leukaemia (AL) including, acute myeloid leukemia (AML), acute promyelocytic leukemia (APL), and acute lymphoblastic leukemia (ALL). Due to the heterogeneity of findings, no meta-analysis was attempted.Results: A total of 13 observational studies, including 11 cohort studies and 2 case control studies, were included with 5,359 participants. Number of patients who developed VTE among the total population was 330 (6.2%; 95% CI 5.5-6.8). Of patients with VTE, 229 patients received treatment with anticoagulation. Agents used for anticoagulation included low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), and vitamin K antagonists (VKA). Despite lack of consensus, most studies adjusted dose of anticoagulant based on platelet (PLT) counts. Most commonly, LMWH dose was reduced by 50-75% for PLT counts less than 50 X 109 /L. Many studies temporarily held anticoagulation in the face of severe thrombocytopenia (PLT <10 X 109/L) refractory to transfusions. Platelet transfusions were often used to maintain PLT count at a safe cut off. The recurrence rate reported varied among different studies based on duration of treatment with anticoagulation and duration of follow up. Recurrence ranged from 0 to 29% in different studies. Reported bleeding rate in the literature was sporadic; however, no studies reported a statistically significant higher risk of bleeding among anti-coagulated patients.Conclusion: In summary, our systematic review obtained information about different anticoagulation regimens used for treatment of VTE in AL patients, highlighting the significant lack of data in this area. In addition, there is a high degree of heterogeneity in choice of anticoagulant, dose adjustments in the face of thrombocytopenia, duration of anticoagulation and bleeding and recurrence rates. Further studies are required to develop guidelines and suggestions for treatment of VTE in AL. [Display omitted] DisclosuresLazo-Langner:Daiichi Sankyo: Research Funding; Pfizer: Honoraria; Bayer: Honoraria; Alexion: Research Funding.

Thrombotic Events in Patients with Myeloma Treated with Immunomodulatory Drugs; Results of the Myeloma XI Study

Thrombotic Events in Patients with Myeloma Treated with Immunomodulatory Drugs; Results of the Myeloma XI Study

Heparins have adequate ex vivo anticoagulant effects in hospitalized patients with cirrhosis

BackgroundPatients with cirrhosis are at risk of venous thromboembolism (VTE), but strategies for thromboprophylaxis have not been defined. Previous in vitro studies suggest an altered anticoagulant effect of heparins in patients with cirrhosis. ObjectivesTo assess the anticoagulant effects of prophylactic low‐molecular‐weight heparin (LMWH) or unfractionated heparin (UFH) doses in patients with cirrhosis in a real‐life clinical setting. MethodsWe studied patients with cirrhosis (n = 16) and acute‐on‐chronic liver failure (ACLF) (n = 14), and compared these with patients without underlying liver disease admitted to non‐liver general medical wards (n = 18) and non‐liver intensive care units (n = 14), respectively. Blood samples were taken before and 4 h after administration of the first dose of LMWH or UFH. We assessed hemostatic status using thrombin generation assays, thrombin‐antithrombin complexes (TAT), and conventional coagulation assays, and included healthy controls (n = 20) to establish reference values. Anti‐Xa activity was determined to estimate peak heparin levels. ResultsBaseline thrombin generation was similar among all cohorts and healthy controls despite alterations in conventional coagulation assays. On heparin, both absolute and proportional changes of thrombin generation were comparable between all four cohorts (−62% to −85%). TAT levels decreased in all cohorts apart from the ACLF cohort, but did not correlate with the proportional change in thrombin generation. Anti‐Xa activity correlated with the proportional change in thrombin generation in patients receiving LMWH, but not in patients receiving UFH. ConclusionsThese data suggest that current prophylactic heparin doses have comparable anticoagulant effects in patients with cirrhosis compared with patients without underlying liver disease.

How Can Rotational Thromboelastometry as a Point-of-Care Method Be Useful for the Management of Secondary Thromboprophylaxis in High-Risk Pregnant Patients?

Thromboprophylaxis with low-molecular-weight heparin (LMWH) for patients with a history of venous thromboembolism (VTE) is suggested. Rotational thromboelastometry (ROTEM®) represents an innovative point-of-care method enabling the complex and quick evaluation of hemostasis. However, there are only episodic cases of its use for hemostasis assessment and guidance of LMWH in pregnancy. Therefore, we provide the results of unique prospective and longitudinal monitoring of hemostasis in high-risk pregnant women, which we used for the individualized optimalization of secondary thromboprophylaxis. According to the shortening of clot formation time (CFT) in EXTEM (p = 0.0007 from the 26th gestational week vs. controls) and INTEM (p = 0.002 from the 35th gestational week), increase in alpha angle (AA) in EXTEM, INTEM, and HEPTEM, and the persistence of increase in maximum clot firmness (MCF) in EXTEM, INTEM, and HEPTEM (p < 0.001 from the 26th and 35th gestational week vs. controls for EXTEM and INTEM, p = 0.0012 from the 26th gestational week in HEPTEM), LMWH dose was modified. Even after the postpartum period, AA in EXTEM was steeper than in controls (p = 0.0007), indicating that hemostasis is not fully normalized after 6–8 weeks following delivery. Therefore, ROTEM may be a useful tool for the individual evaluation of the termination of anticoagulant thromboprophylaxis.

Weight-adjusted versus fixed dose heparin thromboprophylaxis in hospitalized obese patients: A systematic review and meta-analysis

Background: Fixed dose unfractionated or low molecular weight heparin is the recommended treatment for venous thromboembolism (VTE) prevention in hospitalized patients. However, its efficacy has been questioned in obese population. Results of previous studies on weight-adjusted doses of heparin for VTE prevention are contradictory. Different anticoagulant regimens are used in clinical practice, but their role remains to be elucidated.Aims: To clarify the efficacy and safety of weight-adjusted dose heparin for VTE prevention in obese subjects hospitalized for medical and surgical conditions.Methods: Twelve studies were identified as reporting VTE occurrence, major or minor bleeding and anti-Xa levels. A random-effect meta-analysis was conducted to derive odds ratios (OR) comparing fixed vs weight adjusted-doses heparins on VTE occurrence, bleeding, anti-Xa levels. Medical and surgical patients, prospective vs retrospective and quality of studies were extracted for moderators and meta-regression analysis.Results: Weight-adjusted dose heparin administration was not associated with reduced VTE occurrence (6320/13317 patients, OR 1.03, 95% C.I. 0.79 to 1.35), nor increased bleeding (5840/10906 patients, OR 0.84, 95% C.I. 0.65 to 1.08), but it was associated with higher anti-Xa levels (284/294 patients, ES 2.04, 95% C.I. 1.16 to 2.92, p<0.0001). A significant heterogeneity was present for comparison of anti-Xa levels (I2=94%, p=0.0001) but not for VTE occurrence or bleeding (I2=7.6% and 12.8% respectivel). None of the moderators explained the heterogeneity of the results among primary studies.Conclusion: Weight-adjusted dose as compared to fixed-dose of heparins in the prevention of VTE in obese patients was not associated with a lower risk of VTE nor a higher risk of bleeding.