• Russell D Hull, Sebastian M Schellong, Victor F Tapson, Manuel Monreal, Meyer-Michel Samama, Philippe Nicol, Eric Vicaut, Alexander G G Turpie, Roger D Yusen, and EXCLAIM (Extended Prophylaxis for Venous ThromboEmbolism in Acutely Ill Medical Patients With Prolonged Immobilization) study.
• ThrombosisResearch Unit, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada. rdhull@ucalgary.ca
• Ann. Intern. Med. 2010 Jul 6; 153 (1): 8-18.

BackgroundExtended-duration low-molecular-weight heparin has been shown to prevent venous thromboembolism (VTE) in high-risk surgical patients.ObjectiveTo evaluate the efficacy and safety of extended-duration enoxaparin thromboprophylaxis in acutely ill medical patients.DesignRandomized, parallel, placebo-controlled trial. Randomization was computer-generated. Allocation was centralized. Patients, caregivers, and outcome assessors were blinded to group assignment. (ClinicalTrials.gov registration number: NCT00077753) SETTING: 370 sites in 20 countries across North and South America, Europe, and Asia.PatientsAcutely ill medical patients 40 years or older with recently reduced mobility (bed rest or sedentary without [level 1] or with [level 2] bathroom privileges). Eligibility criteria for patients with level 2 immobility were amended to include only those who had additional VTE risk factors (age >75 years, history of VTE, or active or previous cancer) after interim analyses suggested lower-than-expected VTE rates.InterventionEnoxaparin, 40 mg/d subcutaneously (2975 patients), or placebo (2988 patients), for 28 +/- 4 days after receiving open-label enoxaparin for an initial 10 +/- 4 days.MeasurementsIncidence of VTE up to day 28 and of major bleeding events up to 48 hours after the last study treatment dose.ResultsExtended-duration enoxaparin reduced VTE incidence compared with placebo (2.5% vs. 4%; absolute risk difference favoring enoxaparin, -1.53% [95.8% CI, -2.54% to -0.52%]). Enoxaparin increased major bleeding events (0.8% vs. 0.3%; absolute risk difference favoring placebo, 0.51% [95% CI, 0.12% to 0.89%]). The benefits of extended-duration enoxaparin seemed to be restricted to women, patients older than 75 years, and those with level 1 immobility.LimitationEstimates of efficacy and safety for the overall trial population are difficult to interpret because of the change in eligibility criteria during the trial.ConclusionUse of extended-duration enoxaparin reduces VTE more than it increases major bleeding events in acutely ill medical patients with level 1 immobility, those older than 75 years, and women.Primary Funding SourceSanofi-aventis.

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