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Evid Based Nurs 9:51 doi:10.1136/ebn.9.2.51
  • Treatment

Review: once daily LMWH is as effective as twice daily LMWH for initial treatment of venous thromboembolism


 
 Q Is once daily low molecular weight heparin (LMWH) as effective (for reducing recurrent venous thromboembolism [VTE]) and as safe (with respect to major haemorrhagic events) as twice daily LMWH in the initial treatment of VTE?

METHODS

GraphicData sources:

Cochrane Peripheral Vascular Diseases Specialized Trials Register (up to April 2005), Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 1, 2005), Medline (up to April 2005), EMBASE/Excerpta Medica (up to April 2005), and bibliographies of relevant articles.

GraphicStudy selection and assessment:

randomised controlled trials (RCTs) in any language that compared (in an intention to treat analysis) once daily with twice daily use of a fixed dose of subcutaneous LMWH as initial treatment in patients with objectively documented VTE (deep venous thromboembolism [DVT] or pulmonary embolism [PE]). Study quality was assessed using the Jadad scale. Trials without adequate concealment of allocation or without blinded outcome assessment were excluded.

GraphicOutcomes:

symptomatic recurrent VTE (DVT or PE) during initial treatment and during follow up; and major haemorrhagic episodes during initial treatment or within 48 hours after treatment cessation. Secondary outcomes included extension of thrombus size, all cause mortality, and post-thrombotic syndrome.

MAIN RESULTS

5 RCTs (n = 1508) met the selection criteria. 1 of the RCTs enrolled patients with DVT and PE, and the rest included only patients with DVT. Brands of LMWH included dalteparin, enoxaparin, nadroparin, and tinzaparin. In all RCTs, the same generic compounds were used in head to head comparisons of once and twice daily treatment regimens. Meta-analysis was done using a fixed effects model. Once daily and twice daily treatment regimens did not differ for any of the outcomes (table).

CONCLUSION

Once daily low molecular weight heparin (LMWH) is as effective (for reducing recurrent venous thromboembolism [VTE]) and as safe (with respect to major haemorrhagic events) as twice daily LMWH for initial treatment of patients with VTE.

Commentary

  1. Maureen Markle-Reid, RN, PhD
  1. McMaster University, Hamilton, Ontario, Canada

      Treatment with LMWH is as safe and effective as, and more cost effective than, unfractionated heparin (UFH) for initial treatment of VTE and currently represents the standard of care for this condition.1 However, the optimal dosing frequency of LMWH for treatment of VTE has not been fully examined. The review by van Dongen et al compared the efficacy and safety of once daily and twice daily LMWH and concluded that once daily treatment is as effective and safe as twice daily treatment for VTE. These data will be of immediate use to nurses in acute care hospital, outpatient, and community settings who provide care to patients with VTE. A once daily LMWH regimen facilitates outpatient treatment and self management of VTE, decreases admission to hospital or length of hospital stay, and thus, could lead to substantial cost savings.

      However, several caveats should be noted. Firstly, a full economic analysis comparing the 2 dosing frequencies needs to be done. Secondly, the findings apply only to the initial treatment of VTE and not to long term outcomes such as post-thrombotic syndrome. Thirdly, given that the risk of VTE increases with comorbid conditions such as heart failure and malignancy,2 further information is needed regarding the number and type of comorbidities present in participants and specific subgroups who would benefit most. Finally, the studies were limited to hospital settings, and only a small number of patients with PE were included. Further research addressing these areas is warranted. Nevertheless, the findings suggest a safe, effective, and convenient alternative for the treatment of VTE and expand the options for care outside of the traditional hospital setting. Decisions about dosing frequency will depend on the balance between increased convenience, availability of nursing and other healthcare resources, and the potential for cost savings.

      References

      Once daily v twice daily low molecular weight heparin (LMWH) for initial treatment of venous thromboembolism*

      
 
 Q Is once daily low molecular weight heparin (LMWH) as effective (for reducing recurrent venous thromboembolism [VTE]) and as safe (with respect to major haemorrhagic events) as twice daily LMWH in the initial treatment of VTE?

      Footnotes

      • For correspondence: MrC J van Dongen, University of Amsterdam, Amsterdam, The Netherlands. c.j.vandongen{at}amc.uva.nl

      • Source of funding: Scottish Executive UK.

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