Assessment of empiric body mass index-based thromboprophylactic dosing of enoxaparin after bariatric surgery: evidence for dosage adjustment using anti-factor Xa in high-risk patients

Karas LA 1 , Nor Hanipah Z 2 , Cetin D 3 , Schauer PR 4 , Brethauer SA 5 , Daigle CR 6 Show all authors , Aminian A 7

Affiliations 

  • 1 Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Surgery, Avita Health System, Galion, Ohio
  • 2 Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Surgery, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia
  • 3 Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
  • 4 Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio; Pennington Biomedical Research Center, Baton Rouge, Louisiana
  • 5 Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
  • 6 Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio; The Bariatric Center, Cleveland Clinic Akron General, Akron, Ohio
  • 7 Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address: AMINIAA@ccf.org
Surg Obes Relat Dis, 2021 Jan;17(1):153-160.
PMID: 33046419 DOI: 10.1016/j.soard.2020.08.016

Abstract

BACKGROUND: Despite thromboprophylaxis, postoperative deep vein thrombosis and pulmonary embolism occur after bariatric surgery, perhaps because of failure to achieve optimal prophylactic levels in the obese population.

OBJECTIVES: The aim of this study was to evaluate the adequacy of prophylactic dosing of enoxaparin in patients with severe obesity by performing an antifactor Xa (AFXa) assay.

SETTING: An academic medical center METHODS: In this observational study, all bariatric surgery cases at an academic center between December 2016 and April 2017 who empirically received prophylactic enoxaparin (adjusted by body mass index [BMI] threshold of 50 kg/m2) were studied. The AFXa was measured 3-5 hours after the second dose of enoxaparin.

RESULTS: A total of 105 patients were included; 85% were female with a median age of 47 years. In total, 16 patients (15.2%) had AFXa levels outside the prophylactic range: 4 (3.8%) cases were in the subprophylactic and 12 (11.4%) cases were in the supraprophylactic range. Seventy patients had a BMI <50 kg/m2 and empirically received enoxaparin 40 mg every 12 hours; AFXa was subprophylactic in 4 (5.7%) and supraprophylactic in 6 (8.6%) of these patients. Of the 35 patients with a BMI ≥50 who empirically received enoxaparin 60 mg q12h, no AFXa was subprophylactic and 6 (17.1%) were supraprophylactic. Five patients (4.8%) had major bleeding complications. One patient developed pulmonary embolism on postoperative day 35.

CONCLUSION: BMI-based thromboprophylactic dosing of enoxaparin after bariatric surgery could be suboptimal in 15% of patients with obesity. Overdosing of prophylactic enoxaparin can occur more commonly than underdosing. AFXa testing can be a practical way to measure adequacy of pharmacologic thromboprophylaxis, especially in patients who are at higher risk for venous thromboembolism or bleeding.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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