Efficacy of a postoperative regimen of enoxaparin in deep vein thrombosis prophylaxis

Does Anticoagulant Medication Alter Fracture-Healing? A Morphological and Biomechanical Evaluation of the Possible Effects of Rivaroxaban and Enoxaparin Using a Rat Closed Fracture Model

Low molecular weight heparin (LMWH) is routinely used to prevent thromboembolism in orthopaedic surgery, especially in the treatment of fractures or after joint-replacement. Impairment of fracture-healing due to increased bone-desorption, delayed remodelling and lower calcification caused by direct osteoclast stimulation is a well-known side effect of unfractioned heparin. However, the effect of LMWH is unclear and controversial. Recent studies strongly suggest impairment of bone-healing in-vitro and in animal models, characterized by a significant decrease in volume and quality of new-formed callus. Since October 2008, Rivaroxaban (Xarelto) is available for prophylactic use in elective knee- and hip-arthroplasty. Recently, some evidence has been found indicating an in vitro dose independent reduction of osteoblast function after Rivaroxaban treatment. In this study, the possible influence of Rivaroxaban and Enoxaparin on bone-healing in vivo was studied using a standardized, closed rodent fracture-model. 70 male Wistar-rats were randomized to Rivaroxaban, Enoxaparin or control groups. After pinning the right femur, a closed, transverse fracture was produced. 21 days later, the animals were sacrificed and both femora harvested. Analysis was done by biomechanical testing (three-point bending) and micro CT. Both investigated substances showed histomorphometric alterations of the newly formed callus assessed by micro CT analysis. In detail the bone (callus) volume was enhanced (sign. for Rivaroxaban) and the density reduced. The bone mineral content was enhanced accordingly (sign. for Rivaroxaban). Trabecular thickness was reduced (sign. for Rivaroxaban). Furthermore, both drugs showed significant enlarged bone (callus) surface and degree of anisotropy. In contrast, the biomechanical properties of the treated bones were equal to controls. To summarize, the morphological alterations of the fracture-callus did not result in functionally relevant deficits.

Enoxaparin and rivaroxaban have different effects on human mesenchymal stromal cells in the early stages of bone healing

Objectives

Venous thromboembolism (VTE) is a major potential complication following orthopaedic surgery. Subcutaneously administered enoxaparin has been used as the benchmark to reduce the incidence of VTE. However, concerns have been raised regarding the long-term administration of enoxaparin and its possible negative effects on bone healing and bone density with an increase of the risk of osteoporotic fractures. New oral anticoagulants such as rivaroxaban have recently been introduced, however, there is a lack of information regarding how these drugs affect bone metabolism and post-operative bone healing.

Methods

We measured the migration and proliferation capacity of mesenchymal stem cells (MSCs) under enoxaparin or rivaroxaban treatment for three consecutive weeks, and evaluated effects on MSC mRNA expression of markers for stress and osteogenic differentiation.

Results

We demonstrate that enoxaparin, but not rivaroxaban, increases the migration potential of MSCs and increases their cell count in line with elevated mRNA expression of C-X-C chemokine receptor type 4 (CXCR4), tumor necrosis factor alpha (TNFα), and alpha-B-crystallin (CryaB). However, a decrease in early osteogenic markers (insulin-like growth factors 1 and 2 (IGF1, IGF2), bone morphogenetic protein2 (BMP2)) indicated inhibitory effects on MSC differentiation into osteoblasts caused by enoxaparin, but not by rivaroxaban.

Conclusions

Our findings may explain the adverse effects of enoxaparin treatment on bone healing. Rivaroxaban has no significant impact on MSC metabolism or capacity for osteogenic differentiation in vitro.

Cite this article: Dr H. Pilge. Enoxaparin and rivaroxaban have different effects on human mesenchymal stromal cells in the early stages of bone healing. Bone Joint Res 2016;5:95–100. DOI: 10.1302/2046-3758.53.2000595.

Effects of thromboprophylaxis on mesenchymal stromal cells during osteogenic differentiation: an in-vitro study comparing enoxaparin with rivaroxaban

Background

Low-molecular-weight heparins (e.g. Enoxaparin) are widely used to prevent venous thromboembolism after orthopaedic surgery, but there are reports about serious side effects including reduction in bone density and strength. In recent years new oral antithrombotic drugs (e.g. direct Factor Xa-inhibitor, Rivaroxaban) have been used to prevent venous thromboembolism. However, there is lack of information on the effects of these new drugs on human mesenchymal stromal cells during osteogenic differentiation and, therefore, effects during postoperative bone healing.

Methods

We evaluated the effects of Rivaroxaban and Enoxaparin on the proliferation, mRNA and surface receptor expression as well as differentiation capacity of primary human mesenchymal stromal cells during their osteogenic differentiation.

Results

Enoxaparin, but not Rivaroxaban treatment significantly increased human mesenchymal stromal cell (hMSC) proliferation during the first week of osteogenic differentiation while suppressing osteogenic marker genes, surface receptor expression and calcification.

Conclusions

This is the first paper to demonstrate that Rivaroxaban had no significant influence on hMSC differentiation towards the osteogenic lineage, indicating a less affected bone healing process compared with Enoxaparin in vitro. Based on these findings Rivaroxaban seems to be superior to Enoxaparin in early stages of bone healing in vitro.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0966-2) contains supplementary material, which is available to authorized users.

Non-anticoagulant derivatives of heparin for the management of asthma: distant dream or close reality?

INTRODUCTION

Approximately 300 million people worldwide are currently affected by asthma. Improvements in the understanding of the mechanisms involved in such inflammatory airway disorders has led to the recognition of new therapeutic approaches. Heparin, a widely used anticoagulant, has been shown to be beneficial in the management of asthma. It belongs to the family of highly sulphated polysaccharides referred to as glycosaminoglycans, containing a heterogeneous mixture of both anticoagulant and non-anticoagulant polysaccharides. Experimental findings have suggested that heparin has potential anti-asthmatic properties owing to the ability of its non-anticoagulant oligosaccharides to bind and modulate the activity of a wide range of biological molecules involved in the inflammatory process.

AREAS COVERED

This review focuses on the potential mechanisms of action and clinical application of heparin as an anti-inflammatory agent for the management of asthma.

EXPERT OPINION

Heparin may play a significant role in the management of asthma. However, these properties are often hindered by the presence of anticoagulant oligosaccharides, which possess a significant risk of bleeding. Therefore, its therapeutic potential must be explored using well-designed clinical studies that focus on identifying and isolating the anti-inflammatory oligosaccharides of heparin and further elucidating the structure and mechanisms of actions of these non-anticoagulant oligosaccharides.

Ion exchange chromatographic separation and isolation of oligosaccharides of intact low-molecular-weight heparin for the determination of their anticoagulant and anti-inflammatory properties

It is well known that enoxaparin, a widely used anticoagulant and low-molecular-weight heparin containing a large number of oligosaccharides, possesses anti-inflammatory activity. Whilst enoxaparin has shown promising results in various inflammatory disorders, some of its oligosaccharides have anti-inflammatory properties and others increase the risk of bleeding due to their anticoagulant effects. The aim of this study was to develop an effective ion exchange chromatographic (IC) technique which allows the separation, isolation and, consequently, the identification of different oligosaccharides of enoxaparin with or without anticoagulant activity. The developed method utilises a semi-preparative CarboPac PA100 (9 × 250 mm) ion exchange column with sodium chloride gradient elution and UV detection at 232 nm. The method successfully resolved enoxaparin into more than 30 different peaks. IC-derived oligosaccharides with high, moderate, low or no anticoagulant activity were identified using an anti-factor Xa assay. The anti-inflammatory activity of selected oligosaccharides was investigated using the Griess assay. Using this technique, the oligosaccharides of enoxaparin with low or no anticoagulant activity, whilst exhibiting significant anti-inflammatory activity, could be fractionated. This technique can provide a platform to identify the oligosaccharides which are devoid of significant anticoagulant activity and are responsible for the therapeutic effects of enoxaparin that have been observed in various inflammatory conditions.

The effect of a new direct Factor Xa inhibitor on human osteoblasts: an in-vitro study comparing the effect of rivaroxaban with enoxaparin

BACKGROUND

Current treatments for the prevention of thromboembolism include heparin and low-molecular weight heparins (LMWHs). A number of studies have suggested that long term administration of these drugs may adversely affect osteoblasts and therefore, bone metabolism. Xarelto™ (Rivaroxaban) is a new anti-thrombotic drug for the prevention of venous thromboembolism in adult patients undergoing elective hip and knee replacement surgery. The aim of this in vitro study was to investigate the possible effects of rivaroxaban on osteoblast viability, function and gene expression compared to enoxaparin, a commonly used LMWH.

METHODS

Primary human osteoblast cultures were treated with varying concentrations of rivaroxaban (0.013, 0.13, 1.3 and 13 μg/ml) or enoxaparin (1, 10 and 100 μg/ml). The effect of each drug on osteoblast function was evaluated by measuring alkaline phosphatase activity. The MTS assay was used to assess the effect of drug treatments on cell proliferation. Changes in osteocalcin, Runx2 and BMP-2 messenger RNA (mRNA) expression following drug treatments were measured by real-time polymerase chain reaction (PCR).

RESULTS

Rivaroxaban and enoxaparin treatment did not adversely affect osteoblast viability. However, both drugs caused a significant reduction in osteoblast function, as measured by alkaline phosphatase activity. This reduction in osteoblast function was associated with a reduction in the mRNA expression of the bone marker, osteocalcin, the transcription factor, Runx2, and the osteogenic factor, BMP-2.

CONCLUSIONS

These data show that rivaroxaban treatment may negatively affect bone through a reduction in osteoblast function.

Investigation of the effect of heating on the chemistry and antifactor Xa activity of enoxaparin

The objective of this study was to investigate the effects of heating on the chemistry, physical properties and antifactor Xa activity of enoxaparin. Samples of enoxaparin heated at 70 degrees C lost 27% of their initial AFXa activity after 8 h, then activity increased to 94% of the initial activity over the next 4 h. Activity then decreased to 84% of control after 48 h and further to 80% of control over 22 days. The initial activity loss correlated with desulfation as demonstrated by sulfate and amine analysis. Fragmentation of oligosaccharides occurred, as demonstrated by reducing capacity and capillary electrophoresis analysis. Individual enoxaparin fractions obtained by high performance size exclusion chromatography were analysed. Early eluting fractions, containing aggregated oligosaccharides, increased in concentration following heating. Up to 65% of sulfate was lost from some fractions, containing hexa- and octa-saccharides, after 8 h, corresponding with decreased activity. Low mass oligosaccharide fractions increased in concentration and had increased activity between 8 and 12 h. Reversed-phase ion-interaction HPLC analysis supported these findings. Deca-, dodeca- and tetradeca-saccharides were resistant to thermal degradation. Desulfation, fragmentation and aggregation occur during the heating of enoxaparin and result in the initial rapid loss, recovery and subsequent gradual loss of activity.

Investigation of freezing- and thawing-induced biological, chemical, and physical changes to enoxaparin solution

This study investigated the effect of freezing and thawing on the biological, physical, and chemical properties of enoxaparin solution. Solutions were frozen and thawed under different conditions, in the presence or absence of dimethyl sulfoxide (DMSO) or 1,2-propanediol (1,2-PD), and the antifactor Xa (AFXa) activity was determined. Enoxaparin solution lost more than 60% of its AFXa activity when thawed rapidly after freezing at -196 degrees C. The loss of AFXa activity was less with higher freezing temperatures and increased with the number of freeze/thaw cycles, but was independent of the duration of freezing. Slow freezing to -196 degrees C with rapid thawing, or rapid freezing with slow thawing, resulted in negligible loss of AFXa activity. The loss of AFXa activity did not involve the loss of N-sulfate groups, the breakdown of glycosidic bonds or the glassy state transition. Controlling the freezing or thawing conditions, dilution with water or addition of a small percentage of DMSO ameliorated the loss of enoxaparin AFXa activity. The loss in AFXa activity was found by size exclusion chromatography to be primarily due to aggregation and was reversed by sonication in the presence of DMSO. These results may provide insight into solutions for the long-term storage of concentrated or diluted enoxaparin.

VENOUS THROMBOSIS PROPHYLAXIS FOR UROLOGICAL LAPAROSCOPY: FRACTIONATED HEPARIN VERSUS SEQUENTIAL COMPRESSION DEVICES

PURPOSE

Venous thromboembolism (VTE) is a significant postoperative complication. Common methods of VTE prophylaxis include subcutaneous fractionated heparin (FH) and lower extremity sequential compression devices (SCD). There is no conclusive evidence supporting 1 method compared to the other for urological laparoscopy. We examined the rates of postoperative hemorrhagic and thrombotic complications after laparoscopic urological procedures in patients treated with FH or SCD as VTE prophylaxis.

MATERIALS AND METHODS

A prospective database augmented by retrospective chart review included all patients who underwent urological laparoscopic surgery of the upper retroperitoneum at our institution from June 2000 to December 2002. Patients nonrandomly received FH or SCD as VTE prophylaxis beginning on the day of surgery.

RESULTS

A total of 344 patients were included in this study, 172 in the FH group and 172 in the SCD group. Thrombotic complications included VTE and/or pulmonary embolism. Hemorrhagic complications were minor or major, the latter requiring transfusion or other intervention. In both groups the rate of thrombotic complication was 2 of 172 (1.2%). The rate of hemorrhagic complication was 16 of 172 (9.3%) in the FH group, of which 12 of 172 (7.0%) were major. The hemorrhagic complication rate was 6 of 172 (3.5%), with 5 of 172 (2.9%) being major in the SCD group.

CONCLUSIONS

After urological laparoscopy of the upper retroperitoneum, subcutaneous fractionated heparin is associated with increased hemorrhagic complications (p = 0.045), without a reduction in thrombotic complications (p >0.999), compared with sequential compression devices.

Major bleeding rates after prophylaxis against venous thromboembolism: Systematic review, meta-analysis, and cost implications

Objectives: The frequency and consequences of major bleeding associated with anticoagulant prophylaxis for prevention of venous thromboembolism is examined.

Methods: We conducted a systematic review and meta-analysis of controlled trials that reported rates of major bleeding after pharmaceutical thromboprophylaxis in patients undergoing major orthopedic surgery. Thromboprophylactic agents were divided into four groups:warfarin/other coumarin derivatives (WARF), unfractionated heparin (UFH), low molecular weight heparin (LMWH), and pentasaccharide (PS). Meta-analysis was conducted comparing LMWH with each of WARF, UFH, and PS. The frequency of re-operation due to major bleeding was reviewed and combined with published costs to estimate the mean cost of managing major bleeding events in these patients.

Results: Twenty-one studies including 20,523 patients met inclusion criteria for the meta-analysis. No evidence of significant between-trial heterogeneity in risk ratios was found. Combined (fixed effects) relative risks (RR) of major bleeding compared with LMWH were WARF – RR 0.59 (95 percent confidence interval [CI], 0.44–0.80); UFH – RR 1.52 (95 percent CI, 1.04–2.23); PS – RR 1.52 (95 percent CI, 1.11–2.09). Seventy-one studies including 32,433 patients were included in the review of consequences of major bleeding. We estimated that the average cost of major bleeding is $113 per patient receiving thromboprophylaxis.

Conclusions: LMWH results in fewer major bleeding episodes than UFH and PS but more than WARF. These events are costly and clinically important.

Comparison of warfarin use in total knee replacement vs total hip replacement

The purpose of this retrospective study was to determine the efficacy of warfarin prophylaxis against deep vein thrombosis (DVT) in total hip arthroplasty (THA) vs total knee arthroplasty (TKA). A review of venograms in 223 patients with THA and in 189 cases of TKA was carried out. The overall DVT rate in THA was 22%. The overall DVT rate in TKA was 46%. We conclude that combined or alternate methods need to be used to decrease the rate of DVT following TKA to that of THA.

An overview of venous thromboembolism prophylaxis

This symposium reviewed the risk factors and problems associated with venous thromboembolism in surgical patients, especially those patients having total hip replacement. The importance of venous thromboembolism prophylaxis was emphasized by a theoretical analysis indicating that venous thromboembolism in patients having hip replacement not only saves lives but is also effective. A discussion of the pharmacology of low-molecular-weight heparin (LMWH) included a review of its role, clinically and experimentally, in venous thromboembolism prophylaxis. Three of the discussants presented their favorable experiences with LMWH in reducing the incidence of venous thromboembolism in patients having hip replacement. It can be concluded that LMWH does reduce the incidence of venous thromboembolism in patients having hip replacement without causing an increase in blood loss. If its effectiveness and safety remain substantiated, LMWH may soon become the preferred agent for venous thromboembolism prophylaxis.