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The Overuse of Unfractionated Heparin (UFH) versus Low Molecular Weight Heparin (LMWH) in Hospitalized Patient with Acute Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
Steven J. Jubelirer1, Saranya Dinesan1, Christine A. Welch2, Talia E. Alexander1, Mitchell L. Stanley1
1Charleston Area Medical Center/West Virginia University, Charleston, WV, United States/2Charleston Area Medical Center/ Outcomes Research, Charleston , WV, United States

Background: Existing guidelines endorse LMWH rather than UFH in hospitalized patients with acute DVT or PE. In a cost analysis by Klarenbach et al.1, LMWH was more cost-effective than UFH. In a study by McGowan et al.2, the avoid heparin initiative dramatic reduced HIT by 42% when LMWH replaced UFH. Objective: To describe the frequency and characteristics associated with the use of UFH versus LMWH, including complications in hospitalized patients with acute DVT/PE. Methods: A retrospective cohort study of Charleston Area Medical Center patients with acute DVT/PE in 2018. Exclusions included, a creatinine clearance of <30 cc/min, acute coronary syndrome, prior diagnosis of HIT, extremes of weight (BMI>40 kg/m2 and weight <50 kg), or thrombocytopenia. Results: The average age of the 228 patients was 63 years, 54% were male, 26% were diabetic, 53% had hypertension, and 21% were cancer patients. The sample contained 52% PE and 48% DVT patients. UFH was given to 75.4% of the patients and 24.6% received LMWH. There was no difference between UFH (62 16) and LMWH (59 18) in the age (p = .15), females (45% in UFH, 52% in LMWH), (p = .36). Hypertension represented 55% of the UFH patients and 46% of the LMWH group (p = .25), while diabetics were in 28% of the UFH and 20% of the LMWH group (p = .22), and 21% of those with cancer were in the UFH group versus 23% in the LMWH, (p = .7). The BMI between the groups was only slightly higher 30 versus 28, for the UFH and LMWH, respectively (p = .06). The length of stay was UFH (8.5 7 days) and LMWH (8.0 9 days) (p = .7). The median time to a therapeutic PPT was 7 hours and varied with 17%, 6 hours of less; 55%, >6 to 12 hours; 13%, >12 to 18 hours; 7%, >18 to 24 hours; 4%, >24 to 36 hours; and 4%, >36 hours. There were no confirmed HIT cases during the initial admission, but there were four cases of nontraumatic intracerebral hemorrhages all associated with UFH patients who had a median time to therapeutic PPT of 11 hours (range 6 to 20 hours). Conclusions: There was greater use of UFH than LMWH in patients with acute DVT/PE. Disadvantages of UFH include: inter-individual dose requirement, necessity of close therapeutic monitoring, variability of sensitivity of different aPTT reagents to UFH, optimal management of UFH is difficult to achieve with frequent blood sticks, a significant delay in getting the PTT into the therapeutic range, and an 8-10 fold higher risk of HIT. 1. Klarenbach S. et al. Economic Evaluation of Unfractionated Heparin Versus Low-Molecular-Weight Heparin to Prevent Venous Thromboembolism in General Medical and Non-Orthopedic Surgical Patients. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Apr. Results. Available from: https://www.ncbi.nlm.nih.gov/books/NBK476594/ 2. McGowan, K. E. et al. (2016). Reducing the hospital burden of heparin-induced thrombocytopenia: impact of an avoid-heparin program. Blood, 127(16), 1954-1959. https://doi.org/10.1182/blood-2015-07-660001.