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 !
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.