Efficacy and Safety of Anti-Xa-Guided Versus Fixed Dosing of Low Molecular Weight Heparin for Prevention of Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-Analysis : Annals of Surgery

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Efficacy and Safety of Anti-Xa-Guided Versus Fixed Dosing of Low Molecular Weight Heparin for Prevention of Venous Thromboembolism in Trauma Patients

A Systematic Review and Meta-Analysis

Tran, Alexandre MD, MSc*,†,‡; Fernando, Shannon M. MD, MSc‡,§; Gates, Rebecca S. MD; Gillen, Jacob R. MD; Droege, Molly E. PharmD; Carrier, Marc MD, MSc†,#; Inaba, Kenji MD**; Haut, Elliott R. MD, PhD††,‡‡; Cotton, Bryan MD§§; Teichman, Amanda MD∥∥; Engels, Paul T. MD¶¶,##; Patel, Rakesh V. MD; Lampron, Jacinthe MD, MPH*; Rochwerg, Bram MD, MSc¶¶,##,***

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Annals of Surgery 277(5):p 734-741, May 2023. | DOI: 10.1097/SLA.0000000000005754

Abstract

Purpose: 

Trauma patients are at high risk of venous thromboembolism (VTE). We summarize the comparative efficacy and safety of anti-Xa-guided versus fixed dosing for low molecular weight heparin (LMWH) for the prevention of VTE in adult trauma patients.

Methods: 

We searched Medline and Embase from inception through June 1, 2022. We included randomized controlled trials or observational studies comparing anti-Xa-guided versus fixed dosing of LMWH for thromboprophylaxis in adult trauma patients. We incorporated primary data from 2 large observational cohorts. We pooled effect estimates using a random-effects model. We assessed risk of bias using the ROBINS-I tool for observational studies and assessed certainty of findings using GRADE methodology.

Results: 

We included 15 observational studies involving 10,348 patients. No randomized controlled trials were identified. determined that, compared to fixed LMWH dosing, anti-Xa-guided dosing may reduce deep vein thrombosis [adjusted odds ratio (aOR); 0.52, 95% CI: 0.40–0.69], pulmonary embolism (aOR: 0.48, 95% CI: 0.30–0.78) or any VTE (aOR: 0.54, 95% CI: 0.42–0.69), though all estimates are based on low certainty evidence. There was an uncertain effect on mortality (aOR: 1.06, 95% CI: 0.85–1.32) and bleeding events (aOR: 0.84, 95% CI: 0.50–1.39), limited by serious imprecision. We used several sensitivity and subgroup analyses to confirm the validity of our assumptions.

Conclusion: 

Anti-Xa-guided dosing may be more effective than fixed dosing for prevention of deep vein thrombosis, pulmonary embolism, and VTE for adult trauma patients. These promising findings justify the need for a high-quality randomized study with the potential to deliver practice changing results.

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