Achievement of Anticoagulation by Using a Weight-based HeparinDosing Protocol for Obese and Nonobese Patients
William J. Spruill, William E. Wade, W. Gary Huckaby, and Ryan B. Leslie
Am J Health-Syst Pharm 58(22):2143-2146, 2001. © 2001 American Society of Health-System Pharmacists
Abstract and Introduction
The need for different heparin dosing protocols for obese and nonobese patients was studied.A chart review was performed for all patients who received heparin over an eightmonth period at an acute carehospital. Data collected included age, sex, height, actual body weight (ABW), ideal body weight (IBW), initialactivated partial thromboplastin time (aPTT), initial heparin bolus dose, initial heparin i.v. infusion rate, time to initialtargeted aPTT, and final infusion rate.Forty patients met criteria for inclusion: 20 obese patients (greater than 30% over IBW) and 20 nonobese patients(less than 20% over IBW). Mean ± S.D. initial heparin infusion rates for the obese and nonobese groups were14.44 ± 1.29 and 15.04 ± 0.42 units/kg/hr, respectively. Times to targeted aPTT for obese and nonobese patientswere 25.86 ± 12.83 and 25.18 ± 14.76 hours, respectively; mean final infusion rates were 12.94 ± 2.56 and 12.36 ±2.54 units/kg/hr; and percent changes from initial to final infusion rates were 11.84% and 17.76%. There were nosignificant differences in initial or final infusion rates or time to targeted aPTT between the two groups.It is appropriate to use ABW in a weightbased heparin dosing protocol for obese patients.
Heparin has been used for more than 50 years for the prophylaxis and treatment of venous thrombosis andpulmonary embolism, treatment of atrial fibrillation with embolization, and diagnosis and treatment of acute andchronic consumptive coagulopathies.
Traditionally, heparin has been dosed empirically.
Dosing by this methodvaries, but a usual bolus dose equals 5000 units followed by a maintenance i.v. infusion of 1000 units/hr.
However, this regimen often fails to achieve therapeutic goals within the first 24 hours of therapy.
Research over the past decade has shown the importance of achieving rapid anticoagulation and targetedactivated partial thromboplastin time (aPTT) during the first 24 hours after heparin therapy.
In 1993 Raschke etal.
noted that a weightbased heparin dosing protocol was superior to the standard regimen in achieving goalsquickly and reducing the complications associated with the latter. These complications included protracted therapy(increased risk of bleeding), aPTT levels below the targeted range, and increased risk of event recurrence.
Additionally, this weight-based protocol was more cost-effective, since it reduced the need for laboratory monitoringand changes in therapy and the number of bolus doses required to maintain desired aPTTs.
Although weight-based heparin dosing protocols are now accepted, their utility for obese patients is still unclear.Heparin's volume of distribution (40-70 mL/kg) is very similar to blood volume; therefore, patients with larger bloodvolumes (e.g., obese patients) would seem to require more heparin.
However, the blood volume of adiposetissue is less than that of lean tissue.
Even though heparin is not distributed into adipose tissue, cliniciansrecommending doses for obese patients must take into account the extra vasculature of these patients andrecognize that the dose may not increase proportionally with body weight.
The purpose of our study was to assess the need for different heparin dosing protocols for obese and nonobesepatients. Specifically, we examined differences in heparin doses determined with a weight-based protocol that wererequired to achieve targeted aPTTs in these two patient categories.
A chart review was performed for all patients who received heparin from July 1, 1999, through February 28, 2000,in an acute care hospital in Athens, Georgia. Data collected included age, sex, height, actual body weight (ABW),