Assessment of the Heparin and Enoxaparin Prophylaxis Protocol in Patients Receiving Care at Sina Hospital in Tabriz
Abstract
Venous thromboembolism (VTE) poses a significant risk to hospitalized patients, accounting for approximately 10% of morbidity cases among this population. However, preventive measures such as heparin and low molecular weight heparin (LMWH), along with mechanical interventions like graduated compression stockings (GCS), can effectively mitigate this risk. The aim of this study was to investigate the rational use of DVT prophylaxis regimen in hospitalized patients. A prospective and descriptive study was conducted randomly in various wards of the hospital throughout 2017. 335 participants were randomly assessed using an already designed questionnaire containing demographic information (age, weight, height, etc.), medical history, type of prophylaxis administered, laboratory tests, prescribed medications, the Geneva score for thrombosis risk evaluation (low risk: 0-2, high risk: ≥3), and bleeding risk assessment tool (low risk: 0-7, high risk: ≥7). Randomly, the medical records of 335 patients admitted to Sina Hospital and who received VTE prophylaxis with heparin (87.8%), enoxaparin (12.54%), and GCS (1.79%), were carefully reviewed over a period of 12 months. According to the guidelines, only 235 patients (70.1%) required anticoagulant prophylaxis, while the remaining 100 patients (29.8%) were not eligible for such prophylaxis. Additionally, out of the 335 patients studied, only 6 received GCS, although only one patient actually necessitated this intervention. Consequently, the total cost of inappropriate anticoagulant prophylaxis was estimated to be 68,270,500 Rials. The appropriate utilization rate of VTE prophylaxis was 70.1%, with heparin being the most commonly prescribed medication. Further, the study highlights the cost implications of inappropriate prescription practices. To address these issues, educational programs and the implementation of clinical practice guidelines within general Hospitals are highly recommended.
2. Nicholson M, Chan N, Bhagirath V, Ginsberg J. Prevention of venous thromboembolism in 2020 and beyond. J Clin Med 2020;9:2467.
3. Lei YT, Xie JW, Huang Q, Huang W, Pei FX. Benefits of early ambulation within 24 h after total knee arthroplasty: a multicenter retrospective cohort study in China. Mil Med Res 2021;8:1-7.
4. Ayalew MB, Horsa BA, Zeleke MT. Appropriateness of pharmacologic prophylaxis against deep vein thrombosis in medical wards of an Ethiopian referral hospital. Int J Vasc Med 2018;2018:8176898.
5. Wenger N, Sebastian T, Beer JH, Mazzolai L, Aujesky D, Hayoz D, et al. Differences in duration of anticoagulation after pulmonary embolism and deep vein thrombosis: findings from the SWIss Venous ThromboEmbolism Registry (SWIVTER). Thromb Res 2022;220:65-71.
6. Cascella M, Rajnik M, Cuomo A, Dulebohn S, Di Napoli R. StatPearls Publishing. Treasure Island (FL); 2020.
7. Ekenyem SC, Ogunlade AF, Boco NO, Makanjuola A, Solaja TO, Oyelese AT, et al. Deep vein thrombosis and phlegmasia cerulea dolens of the lower limbs: an unusual presentation and an unknown etiology. J Adv Med Med Res 2022;34:349-53.
8. Winter MP, Schernthaner G, Lang I. Chronic complications of venous thromboembolism. J Thromb Haemost 2017;15:1531-40.
9. Menon H, Pillai A, Aussenberg-Rodriguez J, Ambrose J, Youssef I, Griffiths EG, et al. Cost reduction associated with heparin-induced thrombocytopenia panel ordering for enoxaparin versus heparin for prophylactic and therapeutic use: a retrospective analysis in a community hospital setting. Avicenna J Med 2018;8:133-8.
10. Cohen AT, Davidson BL, Gallus AS, Lassen MR, Prins MH, Tomkowski W, et al. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. BMJ 2006;332:325-9.
11. Rautaharju PM, Kooperberg C, Larson JC, LaCroix A. Electrocardiographic predictors of incident congestive heart failure and all-cause mortality in postmenopausal women: the Women's Health Initiative. Circulation 2006;113:481-9.
12. Turetz M, Sideris AT, Friedman OA, Triphathi N, Horowitz JM. Epidemiology, pathophysiology, and natural history of pulmonary embolism. Semin Intervent Radiol. 2018;35:92-8.
13. Gray E, Mulloy B, Barrowcliffe TW. Heparin and low-molecular-weight heparin. Thromb Haemost 2008;99:807-18.
14. Turpie AG, Gent M, Côte R, Levine MN, Ginsberg JS, Powers PJ, et al. A low-molecular-weight heparinoid compared with unfractionated heparin in the prevention of deep vein thrombosis in patients with acute ischemic stroke: a randomized, double-blind study. Ann Intern Med 1992;117:353-7.
15. Shelmerdine L, Nandhra S, Kakkos SK, Caprini J, Stansby G. Thromboprophylaxis: what is the future for high-risk surgical patients? Phlebology 2022;37:81-3.
16. Fan C, Jia L, Fang F, Zhang Y, Faramand A, Chong W, et al. Adjunctive intermittent pneumatic compression in hospitalized patients receiving pharmacologic prophylaxis for venous thromboprophylaxis: a systematic review and meta-analysis. J Nurs Scholarsh 2020;52:397-405.
17. Suna K, Herrmann E, Kröger K, Schmandra T, Müller E, Hanisch E, et al. Graduated compression stockings in the prevention of postoperative pulmonary embolism: a propensity-matched retrospective case-control study of 24 273 patients. Ann Med Surg 2020;56:203-10.
18. Caprini JA, Arcelus JI, Reyna J. Effective risk stratification of surgical and nonsurgical patients for venous thromboembolic disease. Semin Hematol 2001;38:12-9.
19. Nendaz M, Spirk D, Kucher N, Aujesky D, Hayoz D, Beer JH, et al. Multicentre validation of the Geneva Risk Score for hospitalised medical patients at risk of venous thromboembolism. Thromb Haemost 2014;112:531-8.
20. Decousus H, Tapson VF, Bergmann JF, Chong BH, Froehlich JB, Kakkar AK, et al. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest 2011;139:69-79.
21. Severinsen MT, Johnsen SP, Tjønneland A, Overvad K, Dethlefsen C, Kristensen SR. Body height and sex-related differences in incidence of venous thromboembolism: a Danish follow-up study. Eur J Intern Med 2010;21:268-72.
22. Huang W, Goldberg R, Anderson F. Secular trends in occurrence of acute venous thromboembolism: the Worcester VTE Study (1985–2009). J Vasc Surg 2015;61:1100.
23. Arnesen CAL, Veres K, Horváth-Puhó E, Hansen JB, Sørensen HT, Brækkan SK. Estimated lifetime risk of venous thromboembolism in men and women in a Danish nationwide cohort: impact of competing risk of death. Eur J Epidemiol 2022;37:1-9.
24. Barco S, Klok FA, Mahé I, Marchena PJ, Ballaz A, Rubio CM, et al. Impact of sex, age, and risk factors for venous thromboembolism on the initial presentation of first isolated symptomatic acute deep vein thrombosis. Thromb Res 2019;173:166-71.
25. Roach R, Cannegieter S, Lijfering W. Differential risks in men and women for first and recurrent venous thrombosis: the role of genes and environment. J Thromb Haemost 2014;12:1593-600.
26. Anali A, Khiali S, Hamishehkar H. Heparin, enoxaparin, and mechanical prophylaxis utilization evaluation in DVT prophylaxis in a major teaching hospital in West of Iran. J Pharm Care 2021;9:183-9.
27. Laleh M. Investigating the compliance of heparin and enoxaparin usage patterns for prophylaxis in thromboembolic events with standard treatment guidelines [dissertation]. Shiraz University of Medical Sciences; 2013.
28. Taher A, Vichinsky E, Musallam K, Cappellini MD, Viprakasit V, Weatherall SD. For the management of non-transfusion dependent thalassaemia (NTDT). Thalassaemia Int Fed. Nicosia; 2013.
29. Shah SS, Abdi A, Özcem B, Basgut B. The rational use of thromboprophylaxis therapy in hospitalized patients and the perspectives of health care providers in Northern Cyprus. PLoS One 2020;15:e0235495.
30. Fahimi F, Bani AS, Behzad NN, Ghazi TL. Enoxaparin utilization evaluation: an observational prospective study in medical inpatients; 2008.
31. Turpie AG, Hirsh J, Gent M, Julian D, Johnson J. Prevention of deep vein thrombosis in potential neurosurgical patients: a randomized trial comparing graduated compression stockings alone or plus intermittent pneumatic compression with control. Arch Intern Med 1989;149:679-81.
32. Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism. Br J Surg 1999;86:992-1004.
33. Tamowicz B, Mikstacki A, Urbanek T, Zawilska K. Mechanical methods of venous thromboembolism prevention: from guidelines to clinical practice. Pol Arch Intern Med 2019;129:335-41.
34. Mehran K, Mostafa AM, Farshad H, Mehdi M, Mir Mohammad M. Cumulative incidence of venous thromboembolism in a teaching general ICU in Tehran. Pajoohandeh 2011;16:134-8.
35. Pooler C. Porth pathophysiology: concepts of altered health states. Philadelphia: Lippincott Williams & Wilkins; 2009.
36. Katzung BG, editor. Basic & clinical pharmacology. New York: McGraw-Hill; 2021.
| Files | ||
| Issue | Vol 63 No 4 (2025) | |
| Section | Original Articles | |
| Keywords | ||
| Anticoagulants Drug utilization review Enoxaparin Heparin Venous thromboembolism | ||
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