Anticoagulation stewardship quality improvement project to decrease incidence of supratherapeutic activated partial thromboplastic time in overweight cancer patients on unfractionated heparin infusions

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Cancer requiring high-intensity unfractionated heparin anticoagulation (primarily venous thromboembolism) in overweight patients (n=263). Intervention: Adjusted body weight (AdjBW)-based unfractionated heparin (UFH) dosing protocol vs. Actual body weight (ABW)-based unfractionated heparin dosing protocol. Primary outcome: First supratherapeutic aPTT (>99.5 seconds) in the bolus/transition cohort (RR 0.63, 95% CI 0.46-0.86, p=0.004).

Q: What does this research mean for the field?

Adjusted body weight dosing of unfractionated heparin reduces the incidence of initial supratherapeutic aPTTs and shortens the time to therapeutic anticoagulation in overweight cancer patients compared with actual body weight dosing. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Sadika Eslaminejad; Jianliang Dai; Katy M. Toale

doi:10.1007/s11239-026-03409-x

October 30, 2026Journal of Thrombosis and ThrombolysisOpen Access

Anticoagulation stewardship quality improvement project to decrease incidence of supratherapeutic activated partial thromboplastic time in overweight cancer patients on unfractionated heparin infusions

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Key result

Adjusted body weight UFH dosing linked to ~37% lower risk of supratherapeutic aPTTs in cancer.

RR 0.63
95% CI 0.46-0.86
P=0.004
n=263

Why the study?

Standard unfractionated heparin dosing based on actual body weight led to increased rates of supratherapeutic aPTTs in patients with actual body weight >130% of ideal body weight and BMI ≤ 40 kg/m 2. This study evaluated whether using adjusted body weight for initial UFH dosing reduces supratherapeutic aPTTs in these cancer patients.

Does adjusted body weight-based initial unfractionated heparin dosing reduce the incidence of first supratherapeutic activated partial thromboplastin times compared to actual body weight-based dosing in overweight hospitalized cancer patients with actual body weight >130% of ideal body weight and BMI ≤ 40 kg/m2?

Key Points

To determine whether dosing initial unfractionated heparin using adjusted body weight instead of actual body weight reduces supratherapeutic activated partial thromboplastin times in overweight cancer patients.
Single-center quality improvement study analyzing 252 unique high-intensity unfractionated heparin infusions before and after implementing a new electronic order set utilizing adjusted body weight (implemented July 9, 2024).
Included hospitalized cancer patients with actual body weight >130% of ideal body weight and body mass index ≤40 kg/m², evaluated across bolus/transition (n=165) and no bolus (n=98) cohorts.
Assessed the incidence of first supratherapeutic activated partial thromboplastin time (>99.5 seconds) using univariate and multivariable modified Poisson regression models.
In the bolus/transition cohort, first supratherapeutic aPTTs decreased from 64.2% (52/81) pre-intervention to 40.5% (34/84) post-intervention, a 37% relative reduction (RR 0.63; 95% CI: 0.46–0.86; p = 0.004).
In the no bolus cohort, first supratherapeutic aPTTs decreased by 39.2% post-intervention (RR 0.61; 95% CI: 0.38–0.97; p = 0.04).
First therapeutic aPTTs in the bolus/transition cohort increased by 82.1% (RR 1.82; 95% CI: 1.12–2.97; p = 0.03), and median time to first therapeutic aPTT dropped from 14 hours 37 minutes to 8 hours 37 minutes.

Study Design

Type

Observational (n=263)

Blinding

Open-label

Multicenter

No

Structured PICO

Does adjusted body weight-based initial unfractionated heparin dosing reduce the incidence of first supratherapeutic activated partial thromboplastin times compared to actual body weight-based dosing in overweight hospitalized cancer patients with actual body weight >130% of ideal body weight and BMI ≤ 40 kg/m2?

P

Population

263 hospitalized overweight adult cancer patients (median age ~65-67 years, 65.4% female) with actual body weight >130% of ideal body weight and BMI <=40 kg/m2 receiving high-intensity unfractionated heparin infusions across pre- and post-implementation cohorts.

I

Intervention

Adjusted body weight (AdjBW)-based high-intensity intravenous unfractionated heparin (UFH) infusion dosing protocol, calculated as AdjBW = IBW + 0.4 x (ABW - IBW), with an initial infusion dose of 18 units/kg/hour (maximum 2,200 units/hour) and, if applicable, an initial bolus of 80 units/kg (maximum 10,000 units) or transition from prior therapeutic anticoagulation.

C

Comparator

Actual body weight (ABW)-based high-intensity intravenous unfractionated heparin (UFH) infusion dosing protocol with an initial infusion dose of 18 units/kg/hour (maximum 2,200 units/hour) and, if applicable, an initial bolus of 80 units/kg (maximum 10,000 units) or transition from prior therapeutic anticoagulation.

O

Outcome

Percentage change in the number of first supratherapeutic activated partial thromboplastin times (aPTT > 99.5 seconds) before and after the intervention.surrogate

Main Result

Relative Risk: 0.63 (95% CI 0.46–0.86)

Absolute Event Rate: 40.5% vs 64.2%

Absolute Risk Reduction: 24%

p-value: p=0.004

Using adjusted body weight rather than actual body weight for high-intensity unfractionated heparin dosing in overweight cancer patients (ABW >130% IBW and BMI ≤ 40 kg/m2) significantly reduces initial over-anticoagulation (supratherapeutic aPTTs) and shortens the time to therapeutic anticoagulation.

Limitations

Retrospective single-center analysis at a comprehensive cancer center, limiting generalizability
Unclear timing of last outpatient anticoagulant dose prior to hospital admission in some patients
Unclear clinical rationale for provider choice to administer versus omit the initial heparin bolus
Lack of routine baseline anti-Xa testing prior to UFH initiation in patients with recent DOAC exposure
Heparin resistance was not assessed
Routine anti-Xa monitoring was unavailable to correlate with aPTT findings
Clinical bleeding and thrombotic outcomes were not evaluated
Retrospective analysis at a single cancer center which may limit generalizability
Unclear timing of the last dose of home anticoagulation prior to admission due to retrospective nature
Unclear provider rationale for giving versus omitting the initial bolus
Lack of routine anti-Xa testing prior to UFH initiation in patients with recent DOAC exposure or for UFH monitoring
Clinical patient outcomes such as bleeding or thrombotic complications were not evaluated

Implication

Adjusted body weight UFH dosing was associated with fewer supratherapeutic aPTTs; hypothesis-generating for randomized confirmation before practice change in overweight cancer patients.

Abstract

Unfractionated Heparin (UFH) is widely used to treat multiple conditions in hospitalized patients. Standard dosing based on actual body weight (ABW) may lead to over-anticoagulation in overweight patients due to the limited vascularity of adipose tissue. Historically, ABW was used when BMI ≤ 40 kg/m 2 , and adjusted body weight (AdjBW) when BMI > 40 kg/m 2 . However, patients with ABW >130% of ideal body weight (IBW) and BMI ≤ 40 kg/m 2 experienced increased rates of supratherapeutic activated partial thromboplastin times (aPTTs). The objective of this project was to evaluate whether use of AdjBW for initial UFH dosing reduces supratherapeutic aPTTs in cancer patients with ABW >130% of IBW and BMI ≤ 40 kg/m 2 . A new high intensity UFH protocol utilizing AdjBW UFH dosing was implemented on July 9, 2024. This single-center quality improvement study compared the pre- and post-intervention aPTTs in hospitalized cancer patients. In the bolus/transition cohort the percentage of first supratherapeutic aPTTs decreased by 37% (RR 0.63; 95% CI: [0.46–0.86], p = 0.004 and the percentage of first therapeutic aPTTs increased by 82.1% (RR 1.82; 95% CI: [1.12–2.97], p = 0.03. In the no bolus cohort, the percentage of first supratherapeutic aPTTs decreased by 39.2% (RR 0.61; 95% CI 0.38–0.97, p = 0.04). Time to therapeutic aPTT was shorter in the post-implementation arm compared to pre-implementation. In conclusion, AdjBW-based UFH dosing significantly reduced the percentage of first supratherapeutic aPTTs and decreased the time to first therapeutic aPTT in obese cancer patients on the high-intensity UFH protocol.

Discussion

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Cite This Study

Eslaminejad et al. (2026) conducted an observational in Cancer requiring high-intensity unfractionated heparin anticoagulation (primarily venous thromboembolism) in overweight patients (n=263). Adjusted body weight (AdjBW)-based unfractionated heparin (UFH) dosing protocol vs. Actual body weight (ABW)-based unfractionated heparin dosing protocol was evaluated on First supratherapeutic aPTT (>99.5 seconds) in the bolus/transition cohort (RR 0.63, 95% CI 0.46-0.86, p=0.004). Adjusted body weight UFH dosing reduced first supratherapeutic aPTTs by 37% (RR 0.63, 95% CI 0.46-0.86, p=0.004) vs actual body weight dosing in overweight cancer patients.

synapsesocial.com/papers/6ae682bde432e7a5c4ef373b https://doi.org/10.1007/s11239-026-03409-x

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Anticoagulation stewardship quality improvement project to decrease incidence of supratherapeutic activated partial thromboplastic time in overweight cancer patients on unfractionated heparin infusions

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Anticoagulation stewardship quality improvement project to decrease incidence of supratherapeutic activated partial thromboplastic time in overweight cancer patients on unfractionated heparin infusions

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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