DÄ internationalArchive18/2008Treatment of Deep Vein Thrombosis in the Pelvis and Leg: In Reply

Correspondence

Treatment of Deep Vein Thrombosis in the Pelvis and Leg: In Reply

Dtsch Arztebl Int 2008; 105(18): 345. DOI: 10.3238/arztebl.2008.0345b

Viola Hach-Wunderle

LNSLNS We are grateful for the many positive reactions to our article and are glad to provide the following answers to the critical remarks that were expressed.

Dr. Spannagel points out that the low-molecular-weight heparin (LMWH) certoparin is particularly useful in view of the fact that it can be given in a fixed daily dose, independently of the patient's body weight. This can also be seen from our table 1. If this drug is used, it should be borne in mind that patients weighing less than 60 kg should be carefully monitored, as they are at an increased risk of hemorrhage. This recommendation implies that the ideal dosing of certoparin also depends, to some extent, on body weight.

The information we gave about the dosing of low-molecular-weight heparins corresponded to the doses in which they were approved. There is no adequate evidence to date regarding dose adjustment by normal weight (1, 2).

Dr. Rippich raises the issue of a possible limitation of the approval of nadroparin in a single daily dose for the treatment of acute venous thrombosis if the patient is known to have thrombophilia, or if a diagnostic evaluation for thrombophilia has not yet been performed. This supposition is incorrect. Nadroparin is explicitly approved for the treatment of acute venous thrombosis. The information for physicians states, "The administration of nadroparin in two doses per day should be considered in patients with thrombophilia, complicated deep vein thrombosis, or an elevated risk of hemorrhagic complications." This means merely that, if the physician knows that thrombophilia or a very severe or extensive thrombosis is present, a twice-daily application of LMWH can be considered because of its better pharmacokinetics, with a more evenly distributed effect over a 24-hour period.

Dr. Trieb once again gives a stern warning, from the urological point of view, about the accumulation of low-molecular-weight heparins, and fondaparinux as well, in patients with renal failure, leading to a risk of hemorrhage. Here we can only agree. In patients with acute venous thrombosis, the serum creatinine concentration should be determined as part of the initial laboratory testing, and, if the creatinine clearance is impaired, the dose of the medication should be adjusted, or else it should be switched to unfractionated heparin.

The relation between the molecular weight of LMWH and their accumulation in renal failure was published by Professor Dr. S. Alban of the Pharmacology Department at the University of Kiel (3).

In the rare case of uncontrollable hemorrhage, LMWH can be partially antagonized with protamine. If fondaparinux was used for anticoagulation, recombinant factor VII could be considered in order to counteract bleeding.
Fondaparinux is, indeed, a good alternative to LMWH for the treatment of acute venous thrombosis. This is indicated by the extensive study data that are now available, by its simultaneous approval for the treatment of pulmonary embolism, and by the obviated need for regular checking of the platelet count because of the very low risk of an immune reaction.
DOI: 10.3238/arztebl.2008:0345b
1.
DGA. Interdisziplinäre S2-Leitlinie: Diagnostik und Therapie der Bein- und Beckenvenenthrombose und der Lungenembolie. VASA 2005, 34: Suppl 66.
2.
Büller HR, Agnelli G, Hull RD et al.: Antithrombotic therapy for venous thromboembolic disease. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 401–28. MEDLINE
3.
Alban S: Sicherheit trotz therapeutischer Herausforderungen: Das niedermolekulare Heparin Tinzaparin. Hämostaseologie 2004; 24: 1–4.
1. DGA. Interdisziplinäre S2-Leitlinie: Diagnostik und Therapie der Bein- und Beckenvenenthrombose und der Lungenembolie. VASA 2005, 34: Suppl 66.
2. Büller HR, Agnelli G, Hull RD et al.: Antithrombotic therapy for venous thromboembolic disease. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 401–28. MEDLINE
3. Alban S: Sicherheit trotz therapeutischer Herausforderungen: Das niedermolekulare Heparin Tinzaparin. Hämostaseologie 2004; 24: 1–4.