OBJECTIVE: To discuss the role of low-molecular-weight heparins (LMWHs) in the prevention of venous thromboembolism (VTE) in medical and orthopedic surgery patients. VTE prophylaxis trials in these practice settings establishing the current use of LMWHs marketed in the US are included. An overview is also provided of VTE incidence, risk factors, and prophylaxis consensus guidelines. DATA SOURCES AND STUDY SELECTION: Clinical trials, review articles, and meta-analyses for Food and Drug Administration-approved LMWHs were identified from a MEDLINE search (1980-March 2002). Search terms included dalteparin, enoxaparin, internal medicine, low-molecular-weight heparin, orthopedic surgery, risk factors, tinzaparin, and venous thromboembolism. DATA SYNTHESIS: Consensus guidelines are useful as an initial guide to appropriate VTE prophylaxis; however, a review of the primary literature is needed to identify optimal agents, regimens, or interventions. LMWHs have demonstrated sound efficacy in VTE prevention; however, the quantity and quality of literature are not always comparable for the available agents. CONCLUSIONS: Enoxaparin has demonstrated efficacy and safety in VTE prevention in medical patients, whereas information is limited or lacking for dalteparin and tinzaparin. Total hip replacement (THR) trials have been conducted with all US-marketed LMWHs and have demonstrated the efficacy and safety of each agent. Trials specifically establishing the efficacy of an LMWH in total knee replacement surgery (TKR) have been published for enoxaparin. One combination THR and TKR trial has been published for tinzaparin. These trial outcomes have positioned the LMWHs as key alternatives to adjusted-dose warfarin for VTE prophylaxis in orthopedic surgery. Inherent differences between LMWHs prevent the extrapolation of clinical outcomes from 1 trial to another.

Anticoagulants↗

PubMed2002

Combination antithrombotic therapy in acute myocardial infarction.

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Acute Disease↗

PubMed2002

Management challenge with drotrecogin alfa (activated).

Clinical trial results for drotrecogin alfa (activated) are discussed in terms of potential effect on morbidity and total cost of care. Interdisciplinary collaboration is crucial for improving care in health systems; teamwork has been shown to improve outcomes in intensive care and reduce costs. The treatment of sepsis is costly and resource intensive. With existing treatments, drugs account for a lower percentage of the total cost than does care in the intensive care unit. Study results indicate that drotrecogin alfa (activated) reduces mortality in severe sepsis without a major morbidity penalty in 28 days. No difference was found in total resource use over 28 days between patients who received the drug and those who received placebo, even though more patients who received drotrecogin alfa (activated) survived and thus required treatment. Estimated costs per life-year saved fall within the cost-effective range. When drotrecogin alfa (activated) becomes available for clinical use, pharmacists must systematically assess this new therapeutic tool in terms of health value.

Anti-Infective Agents↗