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Examining Some Unanswered Questions Regarding Location of Treatment, Product Type, and Dosing Frequency

Lisa R. Dolovich, PharmD; Jeffrey S. Ginsberg, MD; James D. Douketis, MD; Anne M. Holbrook, MD, PharmD, MSc, FRCPC; Gillian Cheah, BScPharm

Arch Intern Med. 2000;160:181-188.

Objectives  To compare the efficacy and safety of unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) and to examine current controversies in the treatment of venous thromboembolism (VTE) (ie, setting, product type, and frequency of administration).

Methods  Data were abstracted from MEDLINE, HEALTH, previous reviews, personal files, clinical experts, and conference abstracts. Randomized controlled trials of patients diagnosed with acute VTE that compared LMWHs with UFH were included. Independent duplicate assessment was done for methodological quality and data extraction. Data are reported as pooled relative risks (RRs) and 95% confidence intervals (CIs) comparing LMWHs with UFH as determined by the random effects model.

Results  Thirteen studies were included. There was no statistically significant difference in risk between UFH and LMWHs for recurrent VTE (RR, 0.85 [95% CI, 0.65-1.12]), pulmonary embolism (RR, 1.02 [95% CI, 0.64-1.62]), major bleeding (RR, 0.63 [95% CI, 0.37-1.05]), minor bleeding (RR, 1.18 [95% CI, 0.87-1.61]), and thrombocytopenia (RR, 0.85 [95% CI, 0.45-1.62]). There was a statistically significant difference for risk of total mortality (RR, 0.76 [95% CI, 0.59-0.98]) in favor of LMWHs. Inpatient treatment may reduce the risk of major bleeding vs outpatient therapy. Once-daily therapy is as safe and effective as twice-daily therapy when compared indirectly. Different products could not be statistically compared, but qualitative analysis shows that there are no apparent differences in efficacy and safety.

Conclusions  Low-molecular-weight heparins are at least as effective as UFH in preventing recurrent VTE. It is unlikely that LMWHs are superior in the treatment of VTE, but they do show a statistically significant decrease in total mortality. No differences were seen in the development of recurrent VTE dependent on treatment setting. There were no apparent differences between once-daily and twice-daily therapy or among products. Inpatient therapy may be associated with less major bleeding; therefore, if LMWHs are given in the outpatient setting, patients should be rigorously monitored.

From the Centre for Evaluation of Medicines (Drs Dolovich and Holbrook) and the Departments of Pharmacy (Dr Dolovich and Ms Cheah) and Medicine (Drs Douketis and Holbrook), St Joseph's Hospital, Hamilton, Ontario; the Faculty of Pharmacy, University of Toronto, Toronto, Ontario (Dr Dolovich); and the Departments of Family Medicine (Dr Dolovich) and Medicine (Drs Ginsberg, Douketis, and Holbrook), McMaster University Medical Centre, Hamilton.

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