title: Association Between Enoxaparin Dosage Adjusted by Anti-Factor Xa Trough Level and Clinically Evident Venous Thromboembolism After Trauma.
abstract: Trauma patients are at high risk for developing venous thromboembolism (VTE). The VTE rate when enoxaparin sodium is dosed by anti-factor Xa (anti-Xa) trough level is not well described.
  
  
  
  To determine whether targeting a prophylactic anti-Xa trough level by adjusting the enoxaparin dose would reduce the VTE rate in trauma patients.
  
  
  
  Single-institution, historic vs prospective cohort comparison study at an urban, academic, level I trauma center. The prospective cohort was enrolled from August 2014 to May 2015 and compared with a historic cohort admitted from August 2013 to May 2014. Trauma patients who received enoxaparin adjusted by anti-Xa trough level (adjustment group) were compared with those who received enoxaparin sodium at a dosage of 30 mg twice daily (control group). Patients were excluded if they were younger than 18 years, had a length of hospital stay less than 2 days, or had preexisting deep vein thrombosis. Patients were excluded from the adjustment group for changes in the choice of thromboprophylaxis (heparin, enoxaparin once-daily dosing, early ambulation), hospital discharge before initial trough levels could be drawn, or incorrect timing of trough levels.
  
  
  
  Anti-Xa trough levels were monitored in patients in the adjustment group receiving 3 or more consecutive doses of enoxaparin sodium, 30 mg twice daily. Patients with a trough level of 0.1 IU/mL or lower received enoxaparin sodium increased by 10-mg increments. After providing 3 adjusted doses of enoxaparin, the trough level was redrawn and the dosage was adjusted as necessary. Patients in the control group received enoxaparin sodium at a dosage of 30 mg twice daily without adjustments.
  
  
  
  Rates of symptomatic VTE (deep vein thrombosis and pulmonary embolism, confirmed by duplex ultrasonography and chest computed tomographic angiography, respectively) and bleeding risk.
  
  
  
  A total of 205 patients (mean [SD] age, 41.3 [18.2] years; 75.1% male) were studied, 87 in the adjustment group and 118 in the control group, with similar baseline characteristics and injury profiles. Subprophylactic anti-Xa troughs were noted in 73 of 87 patients (83.9%) in the adjustment group, and the majority of patients (57 of 87 patients [65.5%]) required dosage adjustment of enoxaparin sodium to 40 mg twice daily. Incidence of VTE was significantly lower in the adjustment group than in the control group (1.1% vs 7.6%, respectively; P = .046). When the adjustment group was compared with the control group, no significant difference was noted in the rate of packed red blood cell transfusion (6.9% vs 12.7%, respectively; P = .18) or mean (SD) hematocrit at discharge (34.5% [6.3%] vs 33.4% [6.8%], respectively [to convert to proportion of 1.0, multiply by 0.01]; P = .19).
  
  
  
  In this study, subprophylactic anti-Xa trough levels were common in trauma patients. Enoxaparin dosage adjustment may lead to a reduced rate of VTE without an increased risk of bleeding.
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Ara
authors.initials: A
authors.lastname: Ko
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Megan Y
authors.initials: MY
authors.lastname: Harada
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Galinos
authors.initials: G
authors.lastname: Barmparas
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Kevin
authors.initials: K
authors.lastname: Chung
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Russell
authors.initials: R
authors.lastname: Mason
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Dorothy A
authors.initials: DA
authors.lastname: Yim
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Navpreet
authors.initials: N
authors.lastname: Dhillon
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Margulies
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Gewertz
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Ley
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000008:administration & dosage*; D017984:Enoxaparin / Q000008:administration & dosage*; D017707:Erythrocyte Transfusion; D065427:Factor Xa Inhibitors / Q000097:blood*; D005260:Female; D006400:Hematocrit; D006470:Hemorrhage / Q000097:blood / Q000139:chemically induced*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000097:blood / Q000209:etiology / Q000517:prevention & control*; D054556:Venous Thromboembolism / Q000097:blood / Q000209:etiology / Q000517:prevention & control*; D014947:Wounds and Injuries / Q000150:complications; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin; D065427:Factor Xa Inhibitors