Low molecular weight heparin for venous thromboembolic disease
- Gary E Raskob, MSc, PhD
Gary E Raskob, MSc, PhD
- Professor, Biostatistics, Epidemiology and Medicine
- University of Oklahoma Health Sciences Center
- Russell D Hull, MBBS, MSc
Russell D Hull, MBBS, MSc
- Professor of Medicine
- University of Calgary, Canada
- Section Editors
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
- Jess Mandel, MD
Jess Mandel, MD
- Section Editor — Pulmonary Vascular Disease
- Professor of Medicine
- University of California, San Diego
Low molecular weight (LMW) heparin is prepared by depolymerization of unfractionated heparin using chemical methods or enzymes [1-4]. LMW heparin preparations for clinical use have been produced by several companies (table 1). They have an average molecular weight of 4000 to 6500 Daltons; by comparison, commercially available unfractionated heparin has an average molecular weight of 15,000 Daltons. Several LMW heparin preparations have been evaluated by clinical trials. The recommendations contained in this topic review are linked to the strength of the evidence from clinical trials . A firm recommendation is made only when there is supporting evidence from definitive randomized clinical trials.
The current status of LMW heparin in the prevention and treatment of venous thromboembolic disease will be reviewed here. Issues relating to the general prevention of venous thromboembolic disease are discussed separately. (See "Prevention of venous thromboembolic disease in surgical patients" and "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Treatment, prognosis, and follow-up of acute pulmonary embolism in adults".)
Formulations — The LMW heparin preparations have different biochemical and pharmacologic properties and are not interchangeable [2,4,6,7]. Thus, each preparation must be evaluated by clinical trials measuring the outcomes of thromboembolism, bleeding, and mortality. This variability has led to the following communication from the Food and Drug Administration (FDA) in the United States :
"The FDA is alerting physicians and other health professionals to important considerations in the use of LMW heparins, most particularly to the fact that LMW heparins cannot be used interchangeably, unit for unit with heparin, nor can one individual LMW heparin be used interchangeably with another."
The decision to use a LMW heparin preparation for a specific clinical indication should be based upon the available clinical trial data for that particular preparation.
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- USAGE GUIDELINES
- Severe Renal Failure
- Obese Patients
- Cost effectiveness
- PREVENTION OF VTE
- General abdominothoracic surgery
- Hip fracture surgery
- Major trauma
- Critically ill patients
- Elective hip and knee surgery
- - LMW heparin versus unfractionated heparin
- - LMW heparin versus warfarin
- - LMW heparin versus IV dextran
- - LMW heparin versus newer oral anticoagulants
- - Conclusions
- TIMING AND DURATION OF PROPHYLAXIS
- Medical patients
- TREATMENT OF VTE
- Deep venous thrombosis
- - Outpatient treatment
- Existing malignancy
- Pulmonary embolism