Immediate Postoperative Parenteral Anticoagulant in the Patients with Mesenteric Infarction After Intestine Resection – A Retrospective Cohort Research in a Single Institute

Background: Bowel gangrene represents a major fatal event in acute mesenteric infarction. Intestinal resection is inevitable in patients with peritonitis and bowel gangrene. This retrospective study aimed to elucidate the benefit of postoperative parenteral anticoagulant in patients with intestinal resection. Methods: Patients with acute mesenteric infarction and bowel gangrene were recruited retrospectively between January 2007 and December 2019. All patients underwent bowel resection. They were categorized into two groups: patients without immediate enoxaparin (group A) and those with immediate enoxaparin (group B). Both 30-day and 90-day mortalities were analyzed.Results: A total of 85 patients were included, with 29 patients in group A and 56 patients in group B. Patients in group B had both lower 30-day mortality (16.1%) and 90-day mortality (37.5%), compared to patients in group A (30-day mortality: 51.7%, p=0.001; 90-day mortality: 65.5%, p=0.021). In the 30-day mortality multivariate analysis, patients in group B had a better outcome (odds ratio = 0.087, 95% confidence interval between 0.017 and 0.446, p = 0.003). In the 90-day mortality multivariate analysis, patients in group B also had a better outcome (odds ratio = 0.252, 95% confidence interval between 0.065 and 0.983, p = 0.047).Conclusion: Immediate postoperative parenteral anticoagulant improves short-term prognosis in patients with acute mesenteric infarction and intestinal resection.Trial registration: This research was retrospectively approved by Institutional Review Board (IRB) I&II of Taichung Veterans General Hospital (TCVGH-IRB No.CE21256B) on July 28th, 2021. Informed consent waiver was also approved by IRB I&II of Taichung Veterans General Hospital. Declaration of Helsinki and ICH-GCP guidelines were followed during this study.

Effect of low-molecular-weight heparins on anti-Xa peak levels and adverse reactions in Chinese patients with recurrent spontaneous abortion: a single-center, observational study

Objective To compare three commonly used low-molecular-weight heparins (LWMHs) in the treatment of recurrent spontaneous abortion (RSA) by evaluating the anti-Xa peak levels and adverse reactions. Methods In this single-center, observational study, we enrolled 310 patients with RSA in whom anti-Xa levels were measured during pregnancy. Patients were divided into three groups according to the LMWH they used: the nadroparin group, enoxaparin group and dalteparin group. We compared the peak anti-Xa levels and the coagulation status of each group, and analyzed the incidence of adverse reactions, including local allergy, liver and renal dysfunction, and the impact on platelet. Results Patients in the enoxaparin group had a higher anti-Xa peak level than those in the nadroparin group (0.80 ± 0.22 IU/ml vs. 0.61 ± 0.24 IU/ml; P < 0.0001), although most patients in the three groups reached the target concentration of anti-Xa. Furthermore, patients in the enoxaparin group had a more stable anti-Xa levels during pregnancy. In addition, patients in the nadroparin group had a higher rate of local allergy than those in the enoxaparin group (60.5% vs. 42.5%; P = 0.004) and those in the dalteparin group (60.5% vs. 33.3%; P = 0.002). Further examination by the type of local allergy indicated a dramatic difference in pruritus and induration between the nadroparin group and the other two groups. No difference was found in the incidence of liver and renal dysfunction and thrombocytopenia. Conclusion Compared with nadroparin and daltepatin, enoxaparin showed a better performance regarding anti-Xa levels and the incidence of adverse reactions in the treatment of RSA.

Application of thromboelastography in comparing coagulation difference of rivaroxaban and enoxaparin for thromboprophylaxis after total hip arthroplasty

Purpose: The purpose of this study was to compare the coagulation difference in patients with either rivaroxaban or enoxaparin as thromboprophylaxis after total hip arthroplasty (THA) regarding thromboelastography (TEG) and routine coagulation tests. Patients and methods: Two hundred and twenty-eight patients undergoing primary THA were recruited in this study. They were divided into two groups according to a computer-generated random sequence. Patients in the rivaroxaban group received 10 mg of rivaroxaban orally once daily. Patients in the enoxaparin group received 4000 AxaIU (0.4 mL) of enoxaparin subcutaneously once daily. Rivaroxaban and enoxaparin were started 6–8 h after surgery. The administration of the anticoagulant prophylaxis was lasted for a minimum of 14 days. TEG and routine coagulation tests were performed on the day before the operation and 1 day and 7 days after the operation. Results: No difference was observed in the incidence of deep vein thrombosis (DVT) or pulmonary embolism (PE) between the two groups. There was no significant difference with regard to prothrombin time (PT), activated partial thromboplastin time (PTT), international normalized ratio (INR), and thrombin time (TT) between the two groups. However, while considering TEG, R time of the rivaroxaban group was significantly higher than that of the enoxaparin group ( p = 0.003), whereas the maximum amplitude (MA) ( p = 0.036) value and coagulation index (CI) ( p = 0.002) value were significantly lower than those of the enoxaparin group. Conclusion: With regard to TEG analysis, there was coagulation difference in patients with rivaroxaban and those with enoxaparin as thromboprophylaxis after THA. Under recommended dose of rivaroxaban and enoxaparin, patients undergoing THA were in hypercoagulability on 7days postoperative.

The Effect of Aspirin and Enoxaparin on the Prevention of Venous Thromboembolism in Patients With Ankle Sprain and Cast Immobilization: A Randomized Clinical Trial

Background: The incidence of Venous Thromboembolism (VTE) and its prophylaxis in patients with an ankle injury and cast immobilization are controversial. Objectives: This study aimed to investigate the effect of aspirin and enoxaparin on VTE prevention in patients with an ankle sprain and cast immobilization. Methods: In a double-blind, randomized clinical trial, 90 eligible patients were divided into three groups: patients who did not receive the drugs (the control group), patients who received aspirin (325 mg/d) for 3 weeks (the ASA group), and patients who received enoxaparin (40 mg/d subcutaneously) for 3 weeks (the enoxaparin group). After 3 weeks, the plaster was opened, and the D-dimer level was measured if there was a VTE symptom during the study. Otherwise, at the end of the study, the bilateral lower-limb Complete Compression Ultrasonography (CCUS) and color Doppler ultrasound were used to image the lower limb venous system. Results: Sixty-eight patients completed the study. The mean±SD values of D-dimer in the control, ASA, and enoxaparin groups were 0.33 (0.47) μg/dL (Median=0.18 μg/dL), 0.32 (0.14) μg/dL (Median=0.3 μg/dL) and 0.32 (0.25) μg/dL (Median=0.21 μg/dL), respectively (P>0.05). The positive D-dimer was seen in 2 patients (8%) of the control group, 2 patients (8.3%) of the ASA group, and 2 patients (10.5%) of the enoxaparin group (P>0.05). The color Doppler ultrasound was negative in all patients. Conclusion: Because none of the 68 patients in the current study developed VTE during our 30 days follow-up period, it seems that prophylaxis treatment is unnecessary in patients with an ankle sprain and cast immobilization. Further studies on more patients with a longer period of follow-up are recommended.

Enoxaparin vs Fondaparinux in CK-MB Reduction

Ischemic Heart Disease (Non ST Elevated Myocardial Infarction-NSTEMI) is the leading cause of death in Indonesia after Stroke. Enoxaparin and Fondaparinux are the drugs of choice for this condition. However, there is a little study about these drugs in Indonesian people. Therefore, the objective of the study is to determine the effectivity of enoxaparin and fondaparinux in CK-MB reduction in Indonesian people. The methods of the study is retrospective observational study. A total of 43 patients were met inclusion criteria (32 in the enoxaparin group and 11 in the fondaparinux group). The outcome of the study was CK-MB reduction and the time of dyspnea was disappeared. The results of the study showed no statistic difference between enoxaparin and fondaparinux in reducing CK-MB blood plasma level (-29.00 vs -33.09; p 0.715), and also the time of dyspnea was disappeared (3.44 vs 3.09 days; p 0.347). Therefore, the choice of these agents are based on clinical condition, adverse effects and pharmacoeconomic aspects.

PREvention of VENous Thromboembolism in Hemorrhagic Stroke Patients – PREVENTIHS Study: A Randomized Controlled Trial and a Systematic Review and Meta-Analysis

<b><i>Background:</i></b> In this randomized trial, currently utilized standard treatments were compared with enoxaparin for the prevention of venous thromboembolism (VTE) in patients with intracerebral hemorrhage (ICH). <b><i>Methods:</i></b> Enoxaparin (0.4 mg daily for 10 days) was started after 72 h from the onset of ICH. The primary outcome was symptomatic or asymptomatic deep venous thrombosis as assessed by ultrasound at the end of study treatment. The safety of enoxaparin was also assessed. We included the results of this study in a meta-analysis of all relevant studies comparing anticoagulants with standard treatments or placebo. <b><i>Results:</i></b> PREVENTIHS was prematurely stopped after the randomization of 73 patients, due to the low recruitment rate. The prevalence of any VTE at 10 days was 15.8% in the enoxaparin group and 20.0% in the control group (RR 0.79 [95% CI 0.29–2.12]); 2.6% of enoxaparin and 8.6% of standard therapy patients had severe bleedings (RR 0.31 [95% CI 0.03–2.82]). When these results were meta-analyzed with the results of the selected studies (4,609 patients; 194 from randomized trials), anticoagulants were associated with a nonsignificant reduction in any VTE (OR 0.81; 95% CI 0.43–1.51), in pulmonary embolism (OR 0.53; 95% CI, 0.17–1.60), and in mortality (OR 0.85; 95% CI 0.64–1.12) without increase in hematoma enlargement (OR 0.97; 95% CI, 0.31–3.04). <b><i>Conclusions:</i></b> In patients with acute ICH, the use of anticoagulants to prevent VTE was safe but the overall level of evidence was low due to the low number of patients included in randomized clinical trials.

Retrospective Comparison of Doac with Enoxaparin in Gastrointestinal and Urothelial Cancers

Introduction: Venous thromboembolic disease (VTE) is a common cause of morbidity and mortality in patients with cancer. Cancer associated thrombosis (CAT) is associated with poor prognosis, worse survival and increased care costs. Previous trials demonstrated the non-inferiority of DOACs to LMWH for the treatment of CAT, but there is concern for a possible increased incidence of bleeding, particularly in patients with gastrointestinal (GI) and urothelial (GU) cancers. Current guidelines suggest a preference for enoxaparin with these diagnoses. The aim of our study is to elucidate the safety of DOACs in the treatment of GI and GU cancer associated thrombosis at our institution. Methods: Retrospective chart review of patients with GI or GU cancer associated thrombosis who received either enoxaparin or DOACs (apixaban or rivaroxaban) was performed. The baseline characteristics, duration of anticoagulation (AC) and bleeding events (BEs) were compared between the two groups. The bleeding events were classified according to ISTH categories. Statistical analysis was done using R studio (V1.3.1056). Results: All patients from 01/2001 - 01/2020 with active GI or GU cancer and associated thrombosis who had received enoxaparin or a DOAC were included in the study. Of 262 patients reviewed, 206 (78.6 %) received a DOAC and 56 (21.4%) received enoxaparin. The baseline characteristics between the two groups are depicted in Table 1. Patients in the DOAC group had lower ECOG scores than those on enoxaparin: 79.7% of DOAC and 26.8% of enoxaparin patients had ECOG scores of 1-2. Patients on DOACs were less likely to have metastatic disease (58.7% vs. 78.6%) but were more likely to have additional risk factors for bleeding (p=0.004): 24 patients (11.7%) on DOACs were also on an antiplatelet agent (19 on aspirin, 5 on clopidogrel), compared to 4 patients (7.1%) in enoxaparin group (3 on aspirin, 1 on clopidogrel). Clot distribution was similar between the two groups. The majority of patients, 70.4% in the DOAC group and 73.2% in the enoxaparin group, had no BEs. There was no statistically significant difference in the cumulative incidence (CI) of bleeding between the DOAC and enoxaparin groups (p-value 0.65) Figure 1. In the DOAC group, 109 patients (52.9%) received apixaban and 97 patients (47.1%) received rivaroxaban. There were 26 (23.9%) and 35 (36.8%) BE in the apixaban and rivaroxaban subgroups respectively, Table 2. Of those on apixaban, 13/26 had GI bleeding (12 had underlying GI and 1 patient had GU cancer) and 10/26 had GU bleeding(all with underlying GU cancer). Of those on rivaroxaban 18/35 had GI bleeding (all with underlying GI cancer) and 11/35 had GU bleeding (6 patients had GU and 5 had GI cancer). Conclusion: Our study suggests that physician preferences play a major role in the choice of AC. Most physicians preferred DOACs even for patients with GI/GU cancers when patients had better ECOG scores and non-metastatic disease. However, these were also the same patients that were then more likely to have been exposed to additional risk factors for bleeding. BEs between DOACs and enoxaparin were similar and, between the DOACs, somewhat more favorable with apixaban than rivaroxaban. Randomized clinical trials, controlling for physician choice and bleeding risk factor, are necessary valid comparisons for the best choice of anticoagulation. Disclosures No relevant conflicts of interest to declare.

Comparison between Prophylactic versus Therapeutic Doses of Low-Molecular-Weight Heparin in Severely Ill Coronavirus Disease 2019 Patients in Relation to Disease Progression and Outcome

<b><i>Introduction:</i></b> The predominant coagulation abnormalities in patients with coronavirus disease 2019 (COVID-19) suggest a hypercoagulable state and are consistent with uncontrolled clinical observations of an increased risk of venous thromboembolism. <b><i>Aim and Objectives:</i></b> To compare the effect of prophylactic versus therapeutic doses of enoxaparin in the treatment of severe cases of COVID-19 infection. <b><i>Materials and Methods:</i></b> This was a retrospective observational study conducted at Latifa hospital, Dubai. Fifty-nine patients enrolled from March to June 2020 and divided into 2 groups: patients who received the prophylactic dose of enoxaparin (group 1) and patients who received the therapeutic dose of enoxaparin (group 2). <b><i>Results:</i></b> The mean age of all cases was 47.2 ± 10.4 years, while the mean weight was 76.4 ± 13.4 kg. Males represented 79.7% of cases. Blood group “O” was the most frequent blood group (40.9%). None of the cases were smokers or using alcohol. Bronchial asthma, lung diseases, diabetes mellitus, hypertension, CKD, cardiac disease, thyroid disease, and immunodeficiency were present in 1.7, 1.7, 39, 27.1, 5.1, 1.7, 5.1, and 1.7% respectively. There was no significant difference between both study groups regarding personal and medical characteristics, except for hypertension where 35.9% of group 2 (therapeutic) cases were hypertensive compared to 10% of group 1 cases (prophylactic). There was a significant difference between both study groups regarding inflammatory markers improvement duration, duration of MV and O₂ support duration, with longer duration among (therapeutic) group 2 cases compared to group 1 cases (prophylactic). There was a highly significant difference between both study groups regarding ICU admission, as 64% of group 1 cases were admitted compared to 25% of group 1 cases. Similarly, 38.5% of group 2 cases needed MV compared to only 10% of group 1 cases, which was statistically significant. There was no significant difference between both groups regarding bleeding tendency and mortality (<i>p</i> value 0.54). <b><i>Conclusion:</i></b> Our results showed that use of prophylactic dose of enoxaparin might have some benefits compared to the therapeutic dose in terms of less duration of ICU and hospital stay, duration of oxygen support, need and duration of MV, and normalization of inflammatory markers. However, there was no significant difference between the 2 regimens regarding the mortality.

Once-Daily Versus Twice-Daily Enoxaparin for the Treatment of Acute Venous Thromboembolism in Cancer Patients

Background: No randomized controlled trials have investigated enoxaparin once versus twice daily for venous thromboembolism (VTE) treatment in cancer patients. Objective: To compare the safety and efficacy of enoxaparin 1 mg/kg twice daily versus enoxaparin 1.5 mg/kg/day for the treatment of acute VTE in cancer patients. Methods: This was a single-center, retrospective, observational cohort study. Adults with active cancer and an acute VTE were included. The primary outcome evaluated was the incidence of clinically relevant (major and nonmajor) bleeding (CRB) within 30 days of enoxaparin initiation. Secondary outcomes included the incidence of CRB, thrombosis, and death at 30, 90, and 180 days. The study protocol was approved by the institutional review board. Results: A total of 123 patients met inclusion criteria; 85 patients (69%) were treated with once-daily and 38 patients (31%) with twice-daily enoxaparin. CRB was numerically higher at 30 days in the twice-daily enoxaparin group compared with the once-daily group (5.3% vs 2.4%, P = 0.587). There was a nonsignificant higher incidence of CRB in the once-daily enoxaparin group compared with the twice-daily group at 90 days (8.3% vs 8%, P = 1.0) and 180 days (12.5% vs 7.1%, P = 1.0). The composite outcome of CRB, thrombosis, and death was higher at all time points with enoxaparin once daily. Conclusions: Lack of statistical power in this study precludes definitive conclusions. Clinicians may consider twice-daily enoxaparin because of potentially fewer adverse events but may be limited by patient preference and/or financial constraints.

Recurrence of malignancy-associated venous thromboembolism among patients treated with rivaroxaban compared to enoxaparin

Purpose Although low-molecular-weight heparin (LMWH) remains the standard of care, factor Xa inhibitors such as rivaroxaban may serve as an alternative treatment for venous thromboembolism (VTE) in patients with active malignancy. The purpose of the analysis was to evaluate outcomes of VTE management in cancer patients treated with rivaroxaban compared to enoxaparin. Methods This single-center retrospective analysis was conducted on patients with malignancy-associated VTE initiated on treatment with either rivaroxaban or enoxaparin. The primary endpoint was the incidence of recurrent VTE. Secondary outcomes included a comparison in rates of bleeding, mean duration of treatment, and mean time to recurrence of VTE. Results A total of 45 patients were included in each group. The incidence of recurrent VTE was 8.9% in the rivaroxaban group versus 13.3% in the enoxaparin group ( p = 0.53). There were no statistically significant differences in the secondary outcomes with the exception of longer mean duration of treatment in the rivaroxaban group compared to the enoxaparin group (169 vs. 110 days, respectively; p = 0.04). Conclusions This study provides important preliminary information regarding the efficacy and safety of rivaroxaban for treatment of VTE in cancer patients. Although LMWH should remain the standard of care, these results provide initial reassurance that rivaroxaban serves as a viable alternative in the event that injectable anticoagulation is not an acceptable approach to VTE management.