In this episode, I’ll discuss an article about using fondaparinux in critically ill patients with severe renal dysfunction.
Evaluating options for venous thromboembolism (VTE) prophylaxis in critically ill patients is challenging and many issues can limit options including renal failure, bleeding risk, and thrombocytopenia. Fondaparinux use is often limited in critically ill patients due to its contraindication in severe renal dysfunction (SRD).
The study was a prospective, single arm, interventional study. Patients were enrolled from two academic hospitals of the Detroit Medical Center.
Only ICU patients with an estimated creatinine clearance less than 30 ml/min were enrolled. These included patients with acute kidney injury or end-stage renal disease.
Fondaparinux was given at a dose of 2.5 mg subcutaneously every 48 hours. Peak and trough antifactor Xa levels were monitored. Ultrasound was used at baseline and study completion to assess for deep vein thrombosis (DVT). Bleeding complications were also recorded.
Thirty-two patients received a median of 4 doses of fondaparinux. Fondaparinux peak and trough antifactor Xa levels were 0.36 ± 0.18 mg/L and 0.17 ± 0.11 mg/L (mean ± SD), respectively. These levels are similar to those in patients with normal renal function receiving conventional once-daily dosing. No lower extremity DVTs or suspected VTE events occurred. Two patients (6%) had significant bleeding events.
The authors concluded:
In critically ill patients with SRD, an extended interval fondaparinux dosing regimen of 2.5 mg every 48 hours for VTE prophylaxis achieved peak and trough antifactor Xa levels similar to those reported in noncritically ill patients with normal renal function receiving once-daily fondaparinux. This regimen offers an alternative for patients with SRD when heparinoids must be avoided.
The sample size of this study was small, and the bleeding incidence of 6% was not compared against a placebo group. This precludes the study results from being broadly applied to all ICU patients. However, I would consider this regimen in uniquely complex patients with high clotting risk, renal dysfunction, and the need to avoid heparin.
To access my free download area with 20 different resources to help you in your practice, go to pharmacyjoe.com/free.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.