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Assistant Professor College of Pharmacy Adjunct Assistant Professor Department of Family Medicine College of Medicine University of Oklahoma — Schusterman Campus 4502 E. 41st St., Suite 1H37 Tulsa, Oklahoma 74135-2512 FAX 918/660-3580 Doug-Carroll{at}ouhsc.edu
Pharmacy Clinical Coordinator Pharmacy Department Hillcrest Medical Center Tulsa
Published Online, November 5, 2003. www.theannals.com, DOI 10.1345/aph.1C509c
We agree that LMWHs demonstrate many potential advantages over UFH. This is especially true when the occasion arises that allows for outpatient use of LMWH instead of hospitalization. However, our report was directed only at the prevention of VTE — not the treatment of acute thrombosis.
There is also a request for additional information regarding the population and results observed with our program. We should begin by stressing an important point that was reported in our original discussion. Our program was not designed or powered for hypothesis testing of safety or efficacy. Recent grade 1A recommendations from the American College of Chest Physicians regarding general medical patients are to provide prophylaxis with LDUH or LMWH.2 For these reasons, baseline characteristics, safety, and efficacy results were not discussed in more detail. Monitoring was provided in a real-life method. The patients' treating physicians decided how and when to monitor. There were no clinically evident bleeding episodes or other adverse events that required medication changes.
Patients receiving enoxaparin 30 mg every 12 hours or 40 mg/d were identified for potential conversion. Sixty-nine percent of the patients identified were receiving the twice-daily regimen. As stated in our article, physicians were encouraged to prescribe UFH 5000 units subcutaneously every 8 hours. As this was not a controlled trial, physicians were allowed to use any regimen. Based on available literature, most clinicians would encourage the use of every-8-hour dosing instead of twice daily. There was a small number of patients in whom all prophylaxis was discontinued. This primarily occurred when a regimen was initiated by an emergency department physician in a patient who was at low to no risk of VTE. The impact of nursing workload was also addressed in our discussion. The pharmacy and therapeutics committee nursing representative reviewed and approved the substitution program. Implementation of this type of program is certainly an institution-specific decision that should include thoughtful discussion and review.
The final issue raised by Fanikos and Tsilimingras relates to the impact of pharmacists on physician behavior. Published reasons for the poor use of VTE prophylaxis do not include the fact that UFH is an older agent or requires more frequent administration. In fact, the primary reasons provided are the perception that the overall incidence of VTE has decreased, concern regarding bleeding complications in surgical patients, concern regarding heparin-induced thrombocytopenia, and the perception that VTE occurs rarely.2 It is vital that pharmacists provide input in the proper use of medications, especially with the rapidity with which newer, more expensive agents that provide little to no advantage in specific situations are developed. Our time is certainly well utilized in screening for patients at risk for VTE and providing appropriate recommendations for prophylaxis. This is accomplished in our institution by a number of mechanisms including clinical pharmacists' participation with physician rounds and standardized intensive care unit admission orders.
Groce has proposed that it is ill advised for other institutions to consider a pharmacy program such as the one we described. Based on our experiences, we adamantly disagree with the statement. Our program was directed at minimizing medication costs while adhering to published Consensus Committee recommendations.2 We believe there is ample literature supporting the implementation of identical programs.2-5
A number of questions have been raised about the methodology of our program. As we said above, this was not a controlled trial, and physicians were allowed to use any regimen of prophylaxis. Many clinicians no longer support the use of twice-daily UFH. Groce makes an excellent point in referring to the inappropriate utilization of enoxaparin 30 mg twice daily for medical patients. In fact, 69% of the patients we identified for conversion were receiving the twice-daily regimen. We agree that this is a major problem in our institution and is the basis for a pharmacy-led educational effort toward the appropriate provision of VTE prophylaxis.
Groce also brings into question a number of other published reports. Although he states that "several" published trials have demonstrated enoxaparin's superiority over UFH, only 2 abstracts have been referenced. In addition, each of those abstracts was published approximately 2 years prior to the American College of Chest Physicians' recommendations for VTE prophylaxis.2 The referenced report by Goldhaber et al. provides no relevant information to the current discussion. Groce infers that this report provides evidence that UFH results in higher prophylaxis failures than other options. However, there is no information regarding the UFH regimen that was utilized. Was UFH administered, for example, twice daily, three times daily? How many patients in this report received UFH or LMWH? Did a disproportionately higher number of patients receive UFH? No agent or regimen currently recommended prevents 100% of VTEs.
Finally, Groce raises concerns about the interchange or substitution of medications. Although this practice may not be encouraged by the medical societies referenced, therapeutic interchanges are commonplace in the inpatient setting,6,7 particularly for drugs within the same pharmacologic class.6 However, there are institutions that promote the use of UFH for VTE prophylaxis instead of LMWHs.7 We agree that other institutions should devote a good deal of thought and discussion prior to implementing a UFH-LMWH initiative or any other patient care initiatives.
References
Related articles in The Annals:
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