Deep venous thrombosis (DVT) and pulmonary embolism (PE) remain significant heath care problems. Although standard unfractionated heparin effectively treats DVT and PE, low molecular weight heparins (LMWHs) have many theoretical advantages, including less bleeding potential, less thrombocytopenia, improved bioavailability, and more even pharmacokinetics. Additionally, LMWHs are given subcutaneously based on patient weight and do not need to be monitored by blood tests. Multiple studies have compared LMWH to standard heparin for treatment of DVT/PE. LMWHs have a lower risk for major bleeding, recurrent thromboembolic disease, and mortality rate for the treatment of DVT, whereas for PE treatment they are at least equivalent to standard heparin and more convenient. However, not all patients are candidates for such outpatient therapy. The ability to give LMWH subcutaneously and the lack of need for intensive blood monitoring allows for outpatient therapy.
Coon WW, Willis PW3rd, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh community health study. Circulation1973;48:839-846
2.
Anderson FA Jr., Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med1991;151:933-938
3.
Peterson KLAcute pulmonary thromboembolism: has its evolution been redefined ? Circulation1999;99:1280-1283
4.
Hull RD, Pineo GF, Raskob GEThe economic impact of treating deep vein thrombosis with low-molecular-weight heparin: outcome of therapy and health economy aspects. Haemostasis1998;28(Suppl 3):8-16
5.
Hull R., Delmore T., Genton E., et al. Warfarin sodium versus low-dose heparin in the long-term treatment of venous thrombosis. N Engl J Med1979;301:855-858
6.
Lagerstedt CI , Olsson CG, Fagher BO, Oqvist BW, Albrechtsson U.Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet1985;2:515-518
7.
Kearon C., Hirsh J.Management of anticoagulation before and after elective surgery. N Engl J Med1997;336:1506-1511
8.
Hirsh J.Heparin. N Eng J Med1991;324:1565-1574
9.
Douketis JD, Kearon C., Bates S., Duku EK, Ginsberg JSRisk of fatal pulmonary embolism in patients with treated venous thromboembolism . JAMA1998;279:458-462
10.
Hull RD, Raskob GE, Rosenbloom D., et al. Heparin for 5 days as compared with 10 days in the initial treatment of proximal venous thrombosis. N Engl J Med1990;322:1260-1264
Ageno W., Turpie AGLow-molecular-weight heparin in the treatment of pulmonary embolism . Sem Vasc Surg2000;13:189-193
13.
Hirsh J.Low-molecular-weight heparin: a review of the results of recent studies of the treatment of venous thromboembolism and unstable angina. Circulation1998;98:1575-1582
14.
Sarret M.Low molecular weight heparins. Chemical and biological properties . In: Sarret M, Kher A, Toulemonde F, eds. Low Molecular Weight Heparin Therapy: An Evaluation of Clinical Trials Evidence . New York: Marcel Dekker;2000:11-20
15.
Kher A., Sarret M., Toulemonde F.Low molecular weight heparins and protamine neutralization. In: Sarret M, Kher A, Toulemonde F, eds. Low Molecular Weight Heparin Therapy: An Evaluation of Clinical Trials Evidence . New York: Marcel Dekker;2000:456-457
16.
Clagett GP, Anderson FA Jr., Geerts W., et al. et al. Prevention of venous thromboembolism. Chest1998;114:531S-560S
17.
Leizorovicz A.Comparison of the efficacy and safety of low molecular weight heparins and unfractionated heparin in the initial treatment of deep venous thrombosis. An updated meta-analysis. Drugs1996;52:30-37
18.
Siragusa S. , Cosmi B., Piovella F., Hirsh J., Ginsberg JSLow-molecular-weight heparins and unfractionated heparin in the treatment of patients with acute venous thromboembolism: results of a meta-analysis. Am J Med1996;100:269-277
19.
Hull RD, Raskob GE, Pineo GF, et al. Subcutaneous low-molecular-weight heparin compared with continuous intravenous heparin in the treatment of proximal-vein thrombosis. N Engl J Med1992;326:975-982
20.
Levine M., Gent M., Hirsh J., et al. et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med1996;334:677-681
21.
Koopman MM, Prandoni P., Piovella F., et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. N Engl J Med1996;334:682-687
22.
The Columbus Investigators.Low-molecular-weight heparin in the treatment of patients with venous thromboembolism . N Engl J Med1997;337:657-662
23.
Lensing AW, Prins MH, Davidson BL, Hirsh J.Treatment of deep venous thrombosis with low-molecular-weight heparins. A meta-analysis. Arch Intern Med1995;155: 601-607
van den Belt AG, Prins MH, Lensing AW, et al. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism . Cochrane Database of Systematic Reviews [computer file]. (2): C0001100, 2000. 20257683
26.
Simonneau G. , Sors H., Charbonnier B., et al. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group. N Engl J Med1997;337:663-669
27.
Hull RD, Raskob GE, Brant RF, et al. Low-molecular-weight heparin vs heparin in the treatment of patients with pulmonary embolism. American-Canadian Thrombosis Study Group . Arch Intern Med2000;160: 229-236
Groce JB 3rd.Patient outcomes and cost analysis associated with an outpatient deep venous thrombosis treatment program. Pharmacotherapy1998;18:175S-180S
30.
Hull RD, Raskob GE, Rosenbloom D., et al. Treatment of proximal vein thrombosis with subcutaneous low-molecular-weight heparin vs intravenous heparin. An economic perspective. Arch Intern Med1997;157:289-294
31.
van den Belt AG, Bossuyt PM, Prins MH, Gallus AS, Buller HRReplacing inpatient care by outpatient care in the treatment of deep venous thrombosis—an economic evaluation. TASMAN Study Group. Thromb Haemost1998;79:259-263
32.
Lindmarker P., Holmstrom M.Use of low molecular weight heparin (dalteparin), once daily, for the treatment of deep vein thrombosis. A feasibility and health economic study in an outpatient setting. Swedish Venous Thrombosis Dalteparin Trial Group. J Intern Med1996 ;240:395-401
33.
Wells PS, Kovacs MJ, Bormanis J., et al. Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin: a comparison of patient self-injection with homecare injection. Arch Intern Med1998; 158:1809-1812
34.
Harrison L. , McGinnis J., Crowther M., Ginsberg J., Hirsh J.Assessment of outpatient treatment of deep-vein thrombosis with low-molecular-weight heparin. Arch Intern Med1998;158:2001-2003
35.
Dunn AS, Coller B.Outpatient treatment of deep vein thrombosis: translating clinical trials into practice. Amer J Med1999;106:660-669
36.
Proctor MC, Greenfield LJ, Froehlich JB, Montgomery P., Wakefield TWLimitations and value of ambulating treatment of DVT. American Venous Forum, February 1999, Dana Point, CA
