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Survey: management of therapeutically dosed LMWHs in patients with impaired renal function

Low Molecular Weight Heparins (LMWHs) are commonly used anticoagulants for the prevention and treatment of venous thromboembolism (VTE). LMWHs are high-risk drugs with a narrow therapeutic window, that are cleared renally.

Consensus has been reached on how LMWHs should be dosed for prophylactic use and for therapeutic use in the ‘standard’ patient. However, there is uncertainty about whether or not renally impaired patients should be treated with therapeutically dosed LMWHs and with which dosing regimen. For example, some guidelines recommend the use of unfractioned heparin (UFH) [1-6], whereas others state that LMWHs are safer and more effective than UFH [7-9].

Guidelines vary in their advice on dosing strategies of LMWHs and the usefulness of anti-Xa monitoring in patients with renal impairment. Some guidelines advise to apply a dose reduction [1,2,10], whereas others do not [3-6]. Moreover, some guidelines advise to apply dose adjustments based on anti-Xa activity [3-6], whereas others advise not to or to be very cautious with anti-Xa dose adjustments due to a lack of evidence [1,2,10].

To this end, the Dutch Society of Hospital Pharmacy (NVZA) has conducted a survey to identify how patients with renal impairment are currently being treated with LMWHs. In 59 Dutch hospitals, the treatment policies turned out to be very diverse [data not yet published]. This raised the question whether these differences also exist at a European level. We would like to study this by means of this survey and kindly ask you to respond.

Contact
Prof. Karina Meijer, k.meijer@umcg.nl
Tessa Jaspers, PharmD, PhD candidate, t.jaspers@etz.nl
 
Low Molecular Weight Heparins are used for both treatment and prophylaxis of thromboembolism. This survey focuses on THERAPEUTIC use of LMWHs.
2. Which LMWH is used in therapeutic doses in your hospital? (multiple options possible) *This question is required.
3. According to hospital policy, is UFH or LMWH preferred in renally impaired patients? *This question is required.
4. According to hospital policy, is dose reduction of therapeutically dosed LMWHs applied in renally impaired patients? *This question is required.
5. Is a dose reduction applied at the first administered dose? *This question is required.
6. How are subsequent doses adjusted? *This question is required.
7. Is the anti-Xa activity in renally impaired patients routinely determined?
8. What are the target values for the anti-Xa activity in your hospital for therapeutically dosed LMWHs? *This question is required.
9. Are LMWH doses adjusted based on the anti-Xa activity? *This question is required.
10. If dose increase is necessary based on the anti-Xa levels, is a maximum dose applied? *This question is required.
11. In your hospital, is there a protocol with dosing recommendations for therapeutically dosed LMWHs in renally impaired patients? *This question is required.
12. If yes, which literature and/or guidelines are these recommendations based on? (multiple options possible) *This question is required.
13. Is the hospital’s dosing guideline generally supported and used by all medical staff?
  *This question is required.
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