Increased Enoxaparin Dosing for Venous Thromboembolism Prophylaxis in General Trauma Patients

Objective: To review the evidence regarding increased enoxaparin dosing for venous thromboembolism (VTE) prophylaxis in the general trauma patient population. Data Sources: A search of MEDLINE databases (1946 to October 2016) was conducted using the search terms enoxaparin, thromboembolism prophylaxis, venous thromboembolism, trauma, anti-factor Xa, and weight-based dosing. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: Search results were limited to English-language studies conducted in humans. Trials that included only obese patients or nontrauma patients were excluded. Data Synthesis: A total of 7 trials (958 patients) explored the use of increased dosing of enoxaparin for VTE prophylaxis in trauma patients. Patients were divided by enoxaparin dosing strategies: standard dosing of 30 mg twice daily (BID; n = 509), higher initial dosing regimen (n = 216), or dosing based on anti-FXa level adjustments (n = 233). The majority of the 42 total VTE events (64.3%) occurred in the standard dosing regimen. Within each group, VTE was reported in 5.3% of patients in the standard dosing group, 3.2% in the higher initial dosing group, and 4% in the anti-FXa adjustment group. Initial subtherapeutic anti-FXa levels occurred in 33% to 92% of standard dose patients and 9% to 39% of higher initial dose patients. The average weight-based dose required to achieve a therapeutic level ranged between 0.43 and 0.54 mg/kg/dose BID. The overall rate of bleeding was low, with 3 incidents (0.37%) reported. Conclusion: Standard-dose enoxaparin prophylaxis may not be optimal for the general trauma patient population. Weight-based enoxaparin dosing (0.5 mg/kg/dose BID) is an option in trauma patients considered to be at a lower risk of bleeding complications.