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To the Editor: In their study comparing fixed-dosed unfractionated heparin with low-molecular-weight heparin for the treatment of VTE, Dr Kearon and colleagues¹ concluded that fixed-dose subcutaneous unfractionated heparin was as safe and effective as low-molecular-weight-heparin for the initial treatment of patients with acute VTE. This conclusion was based on the results of a well-designed and conducted noninferiority trial that met prespecified margins of absolute difference for the primary end points.

We disagree with this conclusion, which is based on the fundamental assumption that all types of low-molecular-weight heparin have similar efficacy and safety profiles. A noninferiority trial requires that the efficacy of the reference treatment is established. Although the reference treatment was low-molecular-weight heparin, 2 different low-molecular-weight heparins were used as the reference treatment standard (dalteparin in 74% and enoxaparin in 26% of the low-molecular-weight heparin group) based on availability. The study was not powered for subgroup analysis and, therefore, . . . [Full Text of this Article]

Darrell W. Harrington, MD
dharrington@ladhs.org
Division of General Internal Medicine

Ayad Jindeel, MD
Division of General Internal Medicine
Harbor-UCLA Medical Center
Torrance, Calif

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