title: Analysis of enoxaparin dose titration at a large, tertiary teaching facility.
abstract: Therapeutic drug monitoring of enoxaparin with antifactor Xa levels (AXALs) is recommended in some populations; however, the approach to dose titration is poorly described. Our study at a large, tertiary teaching facility examined the dose response to titration of enoxaparin based on AXAL. Patients from 2008 to 2012 receiving enoxaparin were included, provided 2 or more steady state AXAL were obtained within 30 days and that the enoxaparin was prescribed for treatment rather than prophylaxis. The primary outcome was the percentage of dose change required to obtain goal range AXAL following dose titration. Eighty-seven patients were available for analysis with the following key characteristics: renal dysfunction during treatment 72%, obesity 8%, and solid organ transplant 26%. Initial goal AXAL was attained in 27 (31%) patients, and ultimately 54 (62%) patients achieved goal AXAL. Of the 31 patients who had initial AXAL above goal, 13 (42%) patients reached goal with a median dose decrease of 24%. In the 29 patients who had an initial AXAL below goal, 11 (38%) achieved therapeutic AXAL with a median dose increase of 16%. The AXAL monitoring can guide enoxaparin titration with subtherapeutic or supratherapeutic AXAL and an increase or decrease of roughly 20% is suggested as an initial change.
authors.affiliation: Division of Hospital Medicine, Washington University in St. Louis, St Louis, MO, USA jfreer@dom.wustl.edu.
authors.forename: J Matt
authors.initials: JM
authors.lastname: Freer
authors.affiliation: St. Louis College of Pharmacy, St Louis, MO, USA.
authors.forename: Melissa S
authors.initials: MS
authors.lastname: Green
authors.affiliation: Department of Pharmacy, Barnes-Jewish Hospital, St Louis, MO, USA.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Iuppa
authors.affiliation: Department of Pharmacy, Barnes-Jewish Hospital, St Louis, MO, USA.
authors.forename: Eli N
authors.initials: EN
authors.lastname: Deal
authors.affiliation: Division of Hospital Medicine, Washington University in St. Louis, St Louis, MO, USA.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Thoelke
mesh_terms: D000328:Adult; D000368:Aged; D004305:Dose-Response Relationship, Drug; D017984:Enoxaparin / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D007674:Kidney Diseases / Q000139:chemically induced / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies
chemical_list: D017984:Enoxaparin
keywords: antifactor Xa; enoxaparin; therapeutic drug monitoring