LMWH: Expensive but cost-effective
Focus on Utilization Management
LMWH: Expensive but cost-effective
Avoids PT/PTT, reduced LOS in one study
By Elgin K. Kennedy, MD
Editor, The Assertive Utilization and Quality Report
Acute deep vein thrombosis (DVT) is traditionally treated with intravenous heparin followed by oral anticoagulants, but investigators from the University of California in San Francisco say the use of low molecular weight heparin (LMWH) gives a more predictable anticoagulant response, equivalent clinical outcomes, fewer side effects, and the possibility of dramatic cost savings.1
The FDA has approved LMWH only for DVT prevention, but the therapy can also be used safely and efficiently in the treatment of unstable angina and non-Q wave myocardial infarction. The advantages of LMWH are:
• Longer half-life and better bioavailability when given by SQ injection — permitting outpatient therapy with once- or twice-daily administration.
• Avoidance of laboratory monitoring of coagulation [prothrombin time/partial thromboplastin time (PT/PTT), etc.] — in most cases since there is less variability in the anticoagulant response. Also, LMWH is less likely to cause heparin-induced thrombocytopenia, and daily platelet counts are not usually necessary.
• Lower frequency of heparin-associated osteoporosis — occurs in patients who must be on heparin for periods longer than one month.
• Equivalent (or better) efficacy — shown by numerous studies and measured by six-month recurrence rates of DVT.
• Equivalent (or better) safety — shown by numerous studies as measured by major bleeding complications.
Cuts out daily coagulation studies
The use of LMWH makes life easier for attending physicians because it eliminates daily coagulation studies.
One disadvantage is that it is unreliable when used for patients with obesity or renal failure. Another is its cost per day:
LMWH Lovenox (enoxaparin) $47.04
LMWH Fragmin (dalteparin) $13.95
LMWH Normiflo (ardeparin) $30.90
Heparin (standard) $2.00
The extra daily cost for the inpatient use of LMWH can be balanced against the costs incurred with the extra nursing time required for more frequent administration, cost of possible IV access, and cost of daily blood coagulation tests required with standard heparin therapy. The university investigators point to two recent studies that show many patients admitted with DVT can be rapidly and safely discharged for outpatient therapy.
The first study reduced mean hospital length of stay from 6.5 days in the standard heparin group to 1.1 days in the 1 mg/kg enoxaparin SQ bid group. The second study reduced stay from 8.1 days to 2.7 days. Certain patients were excluded because of a high risk of cardiovascular instability, such as acute pulmonary embolism and co-morbidities. In other cases, however, patients were evaluated and treated with LMWH entirely as outpatients.
Reference
1. Hauer KE. Low molecular weight heparin in the treatment of deep venous thrombosis. West J Med 1998; 169: 240-244.
[Editor’s note: The preceding article was first published in the December 1998 issue of The Assertive Utilization and Quality Report — $60 per year (12 issues). For more information, contact Elgin Kennedy, MD, at 204 Second Ave., No. 334, San Mateo, CA 94401. Telephone: (415) 348-3647.]
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