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Ufh

Discussion in 'Critical Care' started by Nick8, Apr 20, 2011.

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  1. Nick8

    Nick8

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    I'm sorry for my stupid question :oops:

    Why do we prescribe UFH for the DVT prophylaxis twice or three times daily but not three or five times?
  2. Intensivist

    Intensivist

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    May I rephrase your question, why do you give UFH instead of LMWH for DVT prophylaxis?
  3. Bostonredsox

    Bostonredsox

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    Hospital bigwigs are cheap. UFH's cost is <<< Lovenox, even the now generic enoxaparin is more expensive then 5k sq UFH q12. They write formularies for whats cheapest, not necessarily whats best.
  4. Nick8

    Nick8

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    Thank you for your reply!:)

    Have you read this article?

    Dalteparin versus Unfractionated Heparin in Critically Ill Patients
    The PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group
    N Engl J Med 2011; 364:1305-1314April 7, 2011


    The conclusion was:

    Among critically ill patients, dalteparin was not superior to unfractionated heparin in decreasing the incidence of proximal deep-vein thrombosis.
  5. Hernandez

    Hernandez Paranoid and Crotchety...

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    except in cancer pts, is lovenox really superior to UFH?
  6. Intensivist

    Intensivist

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    Reason l asked was more of need to control regularly coag's with pts on UFH and theoretically more risk of some complications. And those labs do cost as well.
  7. Nick8

    Nick8

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    May be you're right but I thought that it's an advantage that we can control its effect on coagulation by using APTT. Additionally we can neutralize it by using protamine sulfate. These two things make using of UFH is more controllable than LMWH.:confused:
  8. jdh71

    jdh71 si vis pacem, para bellum

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    LMWH is dosed by weight with GFR as a consideration and it's much easier to deal with because you give it twice a day for therapeutic doses. You do use UFH in patients who may need a procedure such as surgery or a coronary cath, though some of the cardiologists where I train still prefer LMWH. You have less incidence of HIT. All these things makes LMWH a better product IMHO.
  9. Bostonredsox

    Bostonredsox

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    I seem to be seeing more and more patients with horrible renal failure and I am thus seeing alot of notes from the clinical pharmacists saying, 'consider stopping LMWH and switching to a heparin drip'. This is obviously not for DVT prohylaxis but still...people and their damn kidneys.
  10. Bostonredsox

    Bostonredsox

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    Last edited: May 3, 2011
  11. SLUser11

    SLUser11 CRS

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    Every one of your posts feels like a trap/setup for some discussion...seemingly naive/innocent question in an apologetic manner followed by quoting studies, etc....it's sort of an annoying technique. Just bring up a controversial topic if you want to talk about it.

    Anyway, it's late here in Wichita, so I'll have to find the sources later, but I'm pretty sure that Lovenox has been shown to be more effective than Dalteparin, so they're not the same just because they're both LMWH. I'll have to double check it, though.

    As for cost, it really depends how you're dosing it and the frequency. In my hospital, SQ heparin costs $70/dose, which is $210/day at q8 hours, while Lovenox costs $200/dose, which is either $200 or $400/day based on how often you give it. I wasn't even familiar with generic enoxaparin, so that might make LMWH even cheaper.

    For unfractionated heparin, I know that BID dosing has been shown to be inferior to TID dosing for DVT prophylaxis...so I'm not sure if BID dosing should even be discussed.

    For TID heparin (5,000 units) versus once daily lovenox (40mg), the DVT rate will be about the same, so the benefit of LMWH comes in the decreased HIT and decreased bleeding complications. Those are real, and I'll find the studies tomorrow.

    Both Lovenox and Heparin are reversible, although UFH is more predictably reversible with Protamine...you can still reverse LMWH with protamine but it's harder to measure response.

    The above mentioned NEJM study did show a statistically significant difference in PE rates between UFH and Dalteparin (p=0.01, although one could argue 1.3% vs. 2.3% is not clinically significant, tell that to the 19 extra people with PEs).

    Another note is that in a trauma study that measured Factor 10a levels in critically ill patients, Lovenox 40mg daily did not give adequate prophylaxis, while 30mg q12 did...so I give 30q12 to my critically ill patients routinely.

    Lastly, we talk about need to reverse, etc, but neither UFH or LMWH should be causing much significant bleeding at prophylactic doses. I give both types to patients preop/postop all the time without significant effects on bleeding.

    I think UFH and LMWH both have roles in critical care, and I use both frequently. I think the major problem that I see is people holding these drugs inappropriately for surgery or minor bleeding.
  12. Nick8

    Nick8

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    Thank you for your reply,SLUser11!

    I am sorry if my question seems like you said. I only want to know opinion of my colleagues. This question is really controversial for me.

    I've read about BID and TID (about the comparing of their effects on major bleeding and venous thromboembolism). However in my hospital doctors prescribe 5000 IU of UH four times daily ( 20000 daily). They told me that this frequency of the heparin injection allows us to have a constant antocoagulation effect.
  13. SLUser11

    SLUser11 CRS

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    If you really want a "constant anticoagulation effect" then you should just put them on a low-dose heparin drip...or coumadin....of course, that seems pretty absurd. Otherwise, you'd want a heparin with a longer half life. UFH is about 2 hours, and I think Lovenox is 5-6 hours.

    I think the UFH versus LMWH is an unresolved argument since there are several factors playing in...HIT, bleeding, efficacy against DVT/PE, cost, etc...and the studies aren't standardized...one may have Heparin 5K BID or TID, and another 7500 BID...one has lovenox 40 QD and another 30 BID or Fragmin.

    The secret is to read all those studies, come up with a reasonable conclusion, and then talk to your hospital and find out how much it all really costs.

    I think we have yet to find the perfect pill or shot. There are some things in the pipeline that might change the game a little, most of which I heard about in a recent Audio Digest lecture. I believe Europe is working on a once-weekly pill for prophylaxis, and there are several once-daily pills in development.
  14. proman

    proman Member Moderator

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    The surgeons where I did my residency did heparin 5000 units SQ BID (mostly all the belly cases were like this). I never figured it out since BID is clearly inferior to TID dosing and the rate of bleeding shouldn't be significant with TID. As far as I know they still dose this way.

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