Dr.S.Venkatesan MD

The economics of  parenteral  anti-coagulation  took a paradigm shift more than a decade ago.  That was the arrival of low molecular weight heparin in the early 1990s.  The conventional regular heparin ( so called  unpurified /unfractionated )  was ridiculed   over the years. Lobbying   for LMWH was so strong  no one could  dare – stop this pseudo academic onslaught  flying high  with series of powerful articles  in major journals .

The major plus point  claimed for LMWH was   the convenience of administration  without any monitoring .

This convenience masked  some of the vital  truths  about these drugs

• First and foremost ,  LMWH never proved it’s cost  effectiveness  and worthiness in a convincing manner.
• Acute administration  by IV route was rarely practiced globally  which was used in all major trials.
• The onset of action with subcutaneous route  always lagged behind in real ACS.
• It would  seem ,  the  greatest advantage claimed by LMWH ( of not requiring monitoring  ) is the biggest suspect ,  as we would not know , whether the drug really reaches the peak action or not.

If  raw economics  brought these futile drug to the fore front  ,  the  only  possible way to stop this  redundant  drug was again by the  same  economics ! This , exactly  is happening  now . Suddenly , many  research  papers  are coming out   claiming  the superiority of good old heparin  over LMWH .

Thanks to recession , new  global health polices and politics .

This week’s NEJM restores  at- least some of the   stolen credit  to the regular  heparin after 10

long years !

http://www.nejm.org/doi/full/10.1056/NEJMoa1014475?query=TOC

Assumptions and bias

The above observation by the author  can be labeled as an  extreme form of bias against a wonder drug called LMWH.

It may be  argued  not all LMWH can be considered equal .Will the  outcome from the above trial  results be extrapolated to  enoxaparine  as well  ?What  is your gut feeling ? Gut is many times right than  hyped up RCTS !

In a large tertiary  hospital  where we work  , we have  never switched to the LMWH   in the  bygone  decade (  Both in critical care unit and post op unit )  .We have to withstand   a big  hue and cry and  were   even  humiliated for using regular heparin in our ICU . Now  . . . we  stand fully vindicated !

There are many such falsehoods  that  need to be  corrected in the medical literature. Sooner it happens , better for the humans  of  this planet . We should be glad  . . .things are moving in that direction.