1.3.

6 Dosage in Other Disease States

A) Heparin Sodium
1) OBESITY
a) A study based on retrospective chart reviews concluded that actual body weight was the appropriate weight to use in
weight-based heparin dosing protocols for both obese and non-obese subjects. The weight-based protocol of the
institution with which the authors were affiliated was 70 units/kilogram (kg) by bolus, followed by an infusion of 15
units/kg/hour (hr). Subjects were divided into 2 groups, with the obese group comprised of patients greater than 30% over
their ideal body weight (IBW) and the non-obese group comprised of patients not more than 20% over IBW. Mean initial
infusion rates were 14.44 and 15.04 units/kg/hr for the obese and non-obese groups, respectively. Times to targeted
activated partial thromboplastin time (47 to 70 seconds aPTT) for the same 2 groups were 25.86 and 25.18 hr,
respectively. Final infusion rates were 12.94 and 12.36 units/kg/hr for obese and non-obese patients, with percent change
from initial to final infusion rate 11.84% and 17.76%, respectively. No significant differences between groups were found in
initial or final infusion rates or time to target aPTT (Spruill et al, 2001).
b) Due to the large molecular weight of the heparin molecule, it has not been thought necessary to treat an obese
patient any differently than one of normal weight as long as lean body weight is used as a basis for dosing. This thought
has been questioned by investigators who suggest that plasma heparin concentrations are significantly higher in obese
patients than in normal weight subjects (Beerman & Lahnborg, 1981). In addition, the half-life of heparin was reported to
be longer in obese patients (2.13 hours versus 1.36 hours). The authors suggest that heparin dosage be calculated in
terms of estimated ideal body weight.
c) The use of ideal body weight in heparin dosage calculations gives no consideration to blood volume, albeit relatively
low, of adipose tissue. This omission takes on increasing importance as weight increases. A patient required 3800 units of
heparin/hr to attain a plasma heparin concentration of 0.6 unit/milliliter and APTT values of 55 to 75 seconds (Ellison et
al, 1989). This increased heparin requirement was presumed to reflect an expanded blood volume and therefore an
expanded volume of distribution of heparin. Heparin doses calculated based on the patient's estimated blood volume and
mean population pharmacokinetic data for heparin yielded results similar to the dosages actually used.