1
|
Ding K, Yan W, Zhang Y, Li J, Li C, Liang C. The safety and efficacy of NOACs versus LMWH for thromboprophylaxis after THA or TKA: A systemic review and meta-analysis. Asian J Surg 2024:S1015-9584(24)00375-0. [PMID: 38443248 DOI: 10.1016/j.asjsur.2024.02.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/22/2024] [Indexed: 03/07/2024] Open
Abstract
The differences in the safety and efficacy of anticoagulation between different types of new oral anticoagulants(NOACs) and low molecular weight heparin(LMWH) are still controversial. The main purposes of this study were to analyze safety and efficacy of NOACs versus LMWH for thromboprophylaxis, and perform subgroup analyses stratified by individual NOACs and different populations after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Literature search was performed in PubMed, EMBASE, Cochrane Library, CNKI and Wanfang databases until June 31, 2022. This systematic review and meta-analysis included 46 randomized controlled trials (RCT) with 39, 924 patients. We evaluated the safety and efficacy of thromboprophylaxis between LMWH and NOACs. NOACs were more effective in reducing deep vein thrombosis (DVT) (RR0.59; 95%CI 0.49-0.71) and adverse events (RR: 0.96; 95%CI: 0.93-0.99) than LMWH. The subgroup analyses for different anticoagulants revealed that rivaroxaban (RR:0.49; 95%CI:0.36-0.66), apixaban (RR: 0.54; 95%CI: 0.36-0.81) and edoxaban (RR:0.49; 95%CI: 0.32-0.75) have the lower risk of DVT than LMWH. Apixaban (RR:0.89; 95%CI: 0.80-1.00) had superior prevention of bleeding to LMWH. Edoxaban exhibited a lower risk of VTE (RR: 0.46; 95%CI: 0.33-0.65), advantage events (RR: 0.87; 95%CI: 0.82-0.93), and drug-related adverse events (DRAEs) (RR: 0.64; 95%CI: 0.53-0.76) than LMWH. East Asian population was superior to western population for preventing DVT, advantage events, and DRAE using NOACs. In conclusion, NOACs are more effective than LMWH at preventing DVT and adverse events after arthroplasty. Apixaban has lower bleeding than LMWH, and East Asian populations may benefit more than western population from NOACs.
Collapse
Affiliation(s)
- Kai Ding
- Trauma Emergency Center, The Third Hospital of Hebei Medical University, No.139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, People's Republic of China; Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institute of Hebei Province, Hebei, People's Republic of China; Hebei Orthopaedic Clinical Research Center, Hebei, People's Republic of China; NHC Key Laboratory of Intelligent Orthopeadic Equipment (The Third Hospital of Hebei Medical University), People's Republic of China.
| | - Wei Yan
- Department of Pharmacy, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei, People's Republic of China.
| | - Yifan Zhang
- Trauma Emergency Center, The Third Hospital of Hebei Medical University, No.139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, People's Republic of China; Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institute of Hebei Province, Hebei, People's Republic of China; Hebei Orthopaedic Clinical Research Center, Hebei, People's Republic of China; NHC Key Laboratory of Intelligent Orthopeadic Equipment (The Third Hospital of Hebei Medical University), People's Republic of China.
| | - Jiaxing Li
- Trauma Emergency Center, The Third Hospital of Hebei Medical University, No.139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, People's Republic of China; Key Laboratory of Biomechanics of Hebei Province, Orthopaedic Research Institute of Hebei Province, Hebei, People's Republic of China; Hebei Orthopaedic Clinical Research Center, Hebei, People's Republic of China; NHC Key Laboratory of Intelligent Orthopeadic Equipment (The Third Hospital of Hebei Medical University), People's Republic of China.
| | - Congxin Li
- Department of Pharmacy, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei, People's Republic of China.
| | - Chunhui Liang
- Department of Pharmacy, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Qiaoxi District, Shijiazhuang, 050051, Hebei, People's Republic of China.
| |
Collapse
|
2
|
Dubin JA, Bains SS, Hameed D, Remily EA, Moore MC, Mont MA, Nace J, Delanois RE. Trends in Deep Vein Thrombosis Prophylaxis After Total Knee Arthroplasty: 2016 to 2021. J Arthroplasty 2024:S0883-5403(24)00073-1. [PMID: 38325530 DOI: 10.1016/j.arth.2024.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/19/2023] [Accepted: 01/28/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND In 2011, the American Academy of Orthopaedic Surgeons released a consensus recommending venous thromboembolism (VTE) prophylaxis after total knee arthroplasty (TKA). The purpose of our study was to examine (1) incidences of postoperative complications, including pulmonary embolism (PE), deep vein thrombosis (DVT), and transfusion rates; (2) trends from 2016 to 2021 in VTE prophylaxis; and (3) independent risk factors for 90-day total complications following TKA between aspirin, enoxaparin, rivaroxaban, and warfarin. METHODS Using a national, all-payer database from 2016 to 2021, we identified all patients who underwent primary TKA. Exclusions included all patients who had prescribed anticoagulants within 1 year prior to TKA, hypercoagulable states, and cancer. Data were collected on baseline demographics, including age, sex, diabetes, and a comorbidity index, in each of the VTE prophylaxis cohorts. Postoperative outcomes included rates of PE, DVT, and transfusion. Multivariable regressions were performed to determine independent risk factors for total complications at 90 days following TKA. RESULTS From 2016 to 2021, aspirin was the most used anticoagulant (n = 62,054), followed by rivaroxaban (n = 26,426), enoxaparin (n = 20,980), and warfarin (n = 13,305). The cohort using warfarin had the highest incidences of PE (1.8%) and DVT (5.7%), while the cohort using aspirin had the lowest incidences of PE (0.6%) and DVT (1.6%). The rates of aspirin use increased the most from 2016 to 2021 (32.1% to 70.8%), while the rates of warfarin decreased the most (19.3% to 3.0%). Enoxaparin, rivaroxaban, and warfarin were independent risk factors for total complications at 90 days. CONCLUSIONS An epidemiological analysis of VTE prophylaxis use from 2016 to 2021 shows an increase in aspirin following TKA compared to other anticoagulant cohorts in a nationally representative population. This approach provides more insight and a better understanding of anticoagulation trends over this time period in a nationally representative sample.
Collapse
Affiliation(s)
- Jeremy A Dubin
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Sandeep S Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Daniel Hameed
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Ethan A Remily
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Mallory C Moore
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Michael A Mont
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - James Nace
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Ronald E Delanois
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| |
Collapse
|
3
|
Abad Vélaz O, Carbonel Bueno I. Rivaroxaban versus enoxaparin for thromboprophylaxis in orthopedic surgery: A meta-analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023:S1888-4415(23)00196-0. [PMID: 37741360 DOI: 10.1016/j.recot.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 09/09/2023] [Accepted: 09/15/2023] [Indexed: 09/25/2023] Open
Abstract
INTRODUCTION Venous thromboembolism is highly associated with orthopedic surgery, so thromboprophylaxis is an important consideration for orthopedic surgeons. The new oral anticoagulants have clear advantages for clinical practice. OBJECTIVES To analyze the efficacy and safety of rivaroxaban versus enoxaparin for thromboprophylaxis in different orthopedic surgeries. MATERIAL AND METHODS Systematic electronic search of clinical trials was carried out. Data extraction of efficacy outcomes (deep venous thrombosis, pulmonary embolism and death) and safety outcomes (major bleeding and clinical relevant bleeding) was realized. RESULTS Six randomized and controlled clinical trials were included in this meta-analysis. Compared with enoxaparin the risk of venous thromboembolism was lower with rivaroxaban both in different orthopedic surgeries (RR: 0.51; 95% CI: 0.36-0.73; P=.0002). This result was even better and more homogeneous in the analysis of symptomatic deep venous thrombosis outcome (RR: 0.43; 95% CI: 0.28-0.65; P<.0001; I2=0%; P=.49). The risk of bleeding was not significantly higher with rivaroxaban (RR: 1.20; 95% CI: 0.97-1.49; P=.09). CONCLUSIONS Rivaroxaban should be considerate such as a more effective alternative for thromboprophylaxis in orthopedic surgery.
Collapse
Affiliation(s)
- O Abad Vélaz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - I Carbonel Bueno
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Miguel Servet, Zaragoza, España
| |
Collapse
|
4
|
Jones A, Al-Horani RA. Venous Thromboembolism Prophylaxis in Major Orthopedic Surgeries and Factor XIa Inhibitors. Med Sci (Basel) 2023; 11:49. [PMID: 37606428 PMCID: PMC10443384 DOI: 10.3390/medsci11030049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023] Open
Abstract
Venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep vein thrombosis (DVT), poses a significant risk during and after hospitalization, particularly for surgical patients. Among various patient groups, those undergoing major orthopedic surgeries are considered to have a higher susceptibility to PE and DVT. Major lower-extremity orthopedic procedures carry a higher risk of symptomatic VTE compared to most other surgeries, with an estimated incidence of ~4%. The greatest risk period occurs within the first 7-14 days following surgery. Major bleeding is also more prevalent in these surgeries compared to others, with rates estimated between 2% and 4%. For patients undergoing major lower-extremity orthopedic surgery who have a low bleeding risk, it is recommended to use pharmacological thromboprophylaxis with or without mechanical devices. The choice of the initial agent depends on the specific surgery and patient comorbidities. First-line options include low-molecular-weight heparins (LMWHs), direct oral anticoagulants, and aspirin. Second-line options consist of unfractionated heparin (UFH), fondaparinux, and warfarin. For most patients undergoing knee or hip arthroplasty, the initial agents recommended for the early perioperative period are LMWHs (enoxaparin or dalteparin) or direct oral anticoagulants (rivaroxaban or apixaban). In the case of hip fracture surgery, LMWH is recommended as the preferred agent for the entire duration of prophylaxis. However, emerging factor XI(a) inhibitors, as revealed by a recent meta-analysis, have shown a substantial decrease in the occurrence of VTE and bleeding events among patients undergoing major orthopedic surgery. This discovery poses a challenge to the existing paradigm of anticoagulant therapy in this specific patient population and indicates that factor XI(a) inhibitors hold great promise as a potential strategy to be taken into serious consideration.
Collapse
Affiliation(s)
| | - Rami A. Al-Horani
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA 70125, USA;
| |
Collapse
|
5
|
Lee KH, Chang WL, Tsai SW, Chen CF, Wu PK, Chen WM. The impact of Charlson Comorbidity Index on surgical complications and reoperations following simultaneous bilateral total knee arthroplasty. Sci Rep 2023; 13:6155. [PMID: 37061607 PMCID: PMC10105729 DOI: 10.1038/s41598-023-33196-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/08/2023] [Indexed: 04/17/2023] Open
Abstract
Simultaneous bilateral total knee arthroplasty (TKA) might be associated with higher postoperative morbidity and mortality rates compared with staged bilateral TKA. However, risk factors for surgical complications and reoperations following simultaneous bilateral TKA remain elusive. We conducted this retrospective, single-surgeon case series from 2010 through 2019. A total of 1561 patients who underwent simultaneous bilateral TKA procedures were included. The outcome domains included 30-day and 90-day readmission events for medical or surgical complications and 1-year reoperation events. We performed logistic regression analysis and backward stepwise selection to identify possible risk factors, including age, sex, body mass index, diabetes mellitus (DM), rheumatoid arthritis, American Society of Anesthesiologist (ASA) classification, Charlson Comorbidity Index (CCI), receiving venous thromboembolism (VTE) prophylaxis, or blood transfusion. The overall 30-day, 90-day readmission, and 1-year reoperation rates were 2.11%, 2.88%, and 1.41%, respectively. Higher CCI score (CCI = 4+) was a risk factor for 90-day readmission (aOR: 2.783; 95% CI 0.621-12.465), 90 day readmission for surgical complications (aOR: 10.779; 95% CI 1.444-80.458), and 1 year reoperation (aOR: 4.890; 95% CI 0.846-28.260). Other risk factors included older age, higher ASA level, DM, and receiving VTE prophylaxis. In conclusion, high CCI scores were associated with increased risks of surgical complications and reoperations following simultaneous bilateral TKA procedures.
Collapse
Affiliation(s)
- Kun-Han Lee
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Lin Chang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan.
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Beitou District, Taipei, 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| |
Collapse
|
6
|
Shargall Y, Wiercioch W, Brunelli A, Murthy S, Hofstetter W, Lin J, Li H, Linkins LA, Crowther M, Davis R, Rocco G, Morgano GP, Schünemann F, Muti-Schünemann G, Douketis J, Schünemann HJ, Litle VR. Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery. J Thorac Cardiovasc Surg 2023; 165:794-824.e6. [PMID: 36895083 DOI: 10.1016/j.jtcvs.2022.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection, often after multimodality induction therapy, represent among the highest risk groups for postoperative VTE. Currently there are no VTE prophylaxis guidelines specific to these thoracic surgery patients. Evidenced-based recommendations will help clinicians manage and mitigate risk of VTE in the postoperative period and inform best practice. OBJECTIVE These joint evidence-based guidelines from The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons aim to inform clinicians and patients in decisions about prophylaxis to prevent VTE in patients undergoing surgical resection for lung or esophageal cancer. METHODS The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons formed a multidisciplinary guideline panel that included broad membership to minimize potential bias when formulating recommendations. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to public comment. RESULTS The panel agreed on 24 recommendations focused on pharmacological and mechanical methods for prophylaxis in patients undergoing lobectomy and segmentectomy, pneumonectomy, and esophagectomy, as well as extended resections for lung cancer. CONCLUSIONS The certainty of the supporting evidence for the majority of recommendations was judged as low or very low, largely due to a lack of direct evidence for thoracic surgery. The panel made conditional recommendations for use of parenteral anticoagulation for VTE prevention, in combination with mechanical methods, over no prophylaxis for cancer patients undergoing anatomic lung resection or esophagectomy. Other key recommendations include: conditional recommendations for using parenteral anticoagulants over direct oral anticoagulants, with use of direct oral anticoagulants suggested only in the context of clinical trials; conditional recommendation for using extended prophylaxis for 28 to 35 days over in-hospital prophylaxis only for patients at moderate or high risk of thrombosis; and conditional recommendations for VTE screening in patients undergoing pneumonectomy and esophagectomy. Future research priorities include the role of preoperative thromboprophylaxis and the role of risk stratification to guide use of extended prophylaxis.
Collapse
Affiliation(s)
- Yaron Shargall
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, United Kingdom
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Wayne Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Mich
| | - Hui Li
- Department of Thoracic Surgery, Capital Medical University, Beijing, China
| | - Lori-Ann Linkins
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marc Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Roger Davis
- Patient Representative, Burlington, Ontario, Canada
| | - Gaetano Rocco
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Finn Schünemann
- Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
| | - Giovanna Muti-Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Virginia R Litle
- Department of Surgery, Boston University School of Medicine, Boston, Mass
| |
Collapse
|
7
|
Wang C, Lan S, Xie P, Yang R. Efficacy and Safety of Rivaroxaban and Enoxaparin for Thromboprophylaxis Among Total Hip Arthroplasty Patients: A Systematic Review and Meta-Analysis. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023. [PMID: 36716770 DOI: 10.1055/a-1994-7500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is one of the major and potentially life-threatening complications following major orthopedic surgeries. Research evidence comparing the effectiveness of rivaroxaban and enoxaparin for thromboprophylaxis specific to total hip arthroplasty (THA) has been limited. Hence, this review was done to compare the efficacy and safety of rivaroxaban against enoxaparin for thromboprophylaxis after THA. MATERIALS AND METHODS We conducted a search in databases including Medline, EMBASE, ScienceDirect, Google Scholar, and Cochrane Library from inception until May 2021. Randomized controlled trials directly comparing the effectiveness of rivaroxaban and enoxaparin for thromboprophylaxis among patients undergoing THA were eligible for inclusion. Outcome parameters assessed were efficacy in terms of total VTE and all-cause mortality, major VTE, deep vein thrombosis, symptomatic VTE, and safety in terms of major bleeding events, clinically relevant nonmajor bleeding events, minor bleeding events, total bleeding events, drug-related adverse events, and wound infection. We performed a meta-analysis with a random effects model and reported a pooled risk ratio (RR) with a 95% confidence interval (CI). RESULTS Eleven studies, including 9057 participants, were analyzed. Amongst efficacy outcomes, VTE and all-cause mortality pooled an RR of 0.58 (95% CI: 0.34-0.99), major VTE pooled an RR of 0.37 (95% CI: 0.15-0.90), deep vein thrombosis pooled an RR of 0.57 (95% CI: 0.32-1.02), and symptomatic VTE pooled an RR of 0.51 (95% CI: 0.30-0.87). Amongst safety outcomes, major bleeding events pooled an RR of 1.18 (95% CI: 0.77-1.80), total bleeding events pooled an RR of 1.12 (95% CI: 0.93-1.34), drug-related adverse event pooled an RR of 0.99 (95% CI: 0.87-1.12), and wound infection pooled an RR of 1.11 (95% CI: 0.58-2.14). CONCLUSION Rivaroxaban is a more efficacious drug in terms of VTE and all-cause mortality compared to enoxaparin following THA, and rivaroxaban was non-inferior in terms of safety profiles such as wound infection, bleeding, and drug-related adverse events.
Collapse
Affiliation(s)
- Chong Wang
- Orthopaedics, Lishui Central Hospital, Zheijiang, China
| | - Shuhua Lan
- Orthopaedics, Lishui Central Hospital, Zheijiang, China
| | - Panpan Xie
- Orthopaedics, Lishui Central Hospital, Zheijiang, China
| | - Ruifeng Yang
- Orthopaedics, Lishui Central Hospital, Zheijiang, China
| |
Collapse
|
8
|
Huang Z, Xu X, Xu D, Zhao P, Zou M. Efficacy of 11 anticoagulants for the prevention of venous thromboembolism after total hip or knee arthroplasty: A systematic review and network meta-analysis. Medicine (Baltimore) 2023; 102:e32635. [PMID: 36637921 PMCID: PMC9839234 DOI: 10.1097/md.0000000000032635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND To systematically review the efficacy of 11 anticoagulants in the treatment of venous thromboembolism (VTE) after total hip or knee arthroplasty. METHODS PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Data, VIP, and China Biology Medicine databases were electronically searched for studies assessing the efficacy of different anticoagulants for the prevention of VTE after total hip or knee arthroplasty from January 1, 2010, to January 27, 2022. Two reviewers independently screened the literature, extracted data, and graded the evidence using Confidence in Network Meta-Analysis. The network meta-analysis was then performed using Stata 16.0 software and R 4.1.0 software. RESULTS A total of 61 articles were included. The results of network meta-analysis showed that apixaban, edoxaban, fondaparinux, rivaroxaban, and darexaban were the most effective anticoagulants for the prevention of deep vein thrombosis in patients undergoing total hip or knee arthroplasty (P < .05), while there was no difference in the efficacy among the anticoagulants for the prevention of pulmonary embolism (P > .05). CONCLUSION Apixaban, edoxaban, fondaparinux, rivaroxaban, and darexaban have the best efficacy for the prevention of VTE after total hip or knee arthroplasty.
Collapse
Affiliation(s)
- Zhihao Huang
- School of Big Data and Fundamental Sciences, Shandong Institute of Petroleum and Chemical Technology, Dongying, China
| | - Xinru Xu
- College of Food Science, Northeast Agricultural University, Harbin, China
| | - Dan Xu
- Obstetrical department, Lijin County Central Hospital, Dongying, China
| | - Pengfei Zhao
- Department of Clinical Pharmacy, Weifang People’s Hospital, Weifang, China
- * Correspondence: Pengfei Zhao, Department of Clinical Pharmacy, Weifang People’s Hospital, No. 151 Guangwen Street, Kuiwen District, Weifang 261041, China (e-mail: )
| | - Miao Zou
- School of Big Data and Fundamental Sciences, Shandong Institute of Petroleum and Chemical Technology, Dongying, China
| |
Collapse
|
9
|
Shargall Y, Wiercioch W, Brunelli A, Murthy S, Hofstetter W, Lin J, Li H, Linkins LA, Crowther M, Davis R, Rocco G, Morgano GP, Schünemann F, Muti-Schünemann G, Douketis J, Schünemann HJ, Litle VR. Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6889652. [PMID: 36519935 DOI: 10.1093/ejcts/ezac488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection, often after multimodality induction therapy, represent among the highest risk groups for postoperative VTE. Currently there are no VTE prophylaxis guidelines specific to these thoracic surgery patients. Evidenced-based recommendations will help clinicians manage and mitigate risk of VTE in the postoperative period and inform best practice. OBJECTIVE These joint evidence-based guidelines from The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons aim to inform clinicians and patients in decisions about prophylaxis to prevent VTE in patients undergoing surgical resection for lung or esophageal cancer. METHODS The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons formed a multidisciplinary guideline panel that included broad membership to minimize potential bias when formulating recommendations. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to public comment. RESULTS The panel agreed on 24 recommendations focused on pharmacological and mechanical methods for prophylaxis in patients undergoing lobectomy and segmentectomy, pneumonectomy, and esophagectomy, as well as extended resections for lung cancer. CONCLUSIONS The certainty of the supporting evidence for the majority of recommendations was judged as low or very low, largely due to a lack of direct evidence for thoracic surgery. The panel made conditional recommendations for use of parenteral anticoagulation for VTE prevention, in combination with mechanical methods, over no prophylaxis for cancer patients undergoing anatomic lung resection or esophagectomy. Other key recommendations include: conditional recommendations for using parenteral anticoagulants over direct oral anticoagulants, with use of direct oral anticoagulants suggested only in the context of clinical trials; conditional recommendation for using extended prophylaxis for 28 to 35 days over in-hospital prophylaxis only for patients at moderate or high risk of thrombosis; and conditional recommendations for VTE screening in patients undergoing pneumonectomy and esophagectomy. Future research priorities include the role of preoperative thromboprophylaxis and the role of risk stratification to guide use of extended prophylaxis. (J Thorac Cardiovasc Surg 2022;▪:1-31).
Collapse
Affiliation(s)
- Yaron Shargall
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, United Kingdom
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wayne Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Hui Li
- Department of Thoracic Surgery, Capital Medical University, Beijing, China
| | - Lori-Ann Linkins
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marc Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Roger Davis
- Patient Representative, Burlington, Ontario, Canada
| | - Gaetano Rocco
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Finn Schünemann
- Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
| | - Giovanna Muti-Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Virginia R Litle
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
10
|
Badge H, Churches T, Naylor JM, Xuan W, Armstrong E, Gray L, Fletcher J, Gosbell I, Christine Lin CW, Harris IA. Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study. J Patient Rep Outcomes 2022; 6:110. [PMID: 36224453 PMCID: PMC9556685 DOI: 10.1186/s41687-022-00502-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/02/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery. METHODS This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs. RESULTS The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = - 0.02 SE = 0.008, p = 0.011) and 365-days (β = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = - 0.06, SE = 0.41, p = 0.880 EQ-5D: β = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect. CONCLUSIONS Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.
Collapse
Affiliation(s)
- Helen Badge
- Whitlam Orthopaedic Research Centre, 1 Campbell Street, Liverpool, 2071 Australia ,grid.1005.40000 0004 4902 0432South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071 Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia ,grid.411958.00000 0001 2194 1270Australian Catholic University, 8-20 Napier Street, North Sydney, 2060 Australia
| | - Tim Churches
- grid.1005.40000 0004 4902 0432South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071 Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia
| | - Justine M. Naylor
- Whitlam Orthopaedic Research Centre, 1 Campbell Street, Liverpool, 2071 Australia ,grid.1005.40000 0004 4902 0432South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071 Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia
| | - Wei Xuan
- grid.1005.40000 0004 4902 0432South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071 Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia
| | - Elizabeth Armstrong
- grid.1005.40000 0004 4902 0432School of Population Health, The University of New South Wales, High St Kensington, Kensington, NSW 2052 Australia
| | - Leeanne Gray
- grid.410692.80000 0001 2105 7653South Western Sydney Local Health District, 1 Elizabeth Street, Liverpool, 2071 Australia
| | - John Fletcher
- grid.1013.30000 0004 1936 834XUniversity of Sydney, Fisher Road, Camperdown, NSW 2006 Australia ,grid.413252.30000 0001 0180 6477Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW 2145 Australia
| | - Iain Gosbell
- grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia ,grid.1029.a0000 0000 9939 5719Western Sydney University, Campbelltown, NSW 2560 Australia
| | - Chung-Wei Christine Lin
- grid.1013.30000 0004 1936 834XSydney School of Public Health, The University of Sydney, Edward Ford Building (A27) Fisher Road, Camperdown, NSW 2006 Australia
| | - Ian A. Harris
- Whitlam Orthopaedic Research Centre, 1 Campbell Street, Liverpool, 2071 Australia ,grid.1005.40000 0004 4902 0432South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071 Australia ,grid.429098.eIngham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071 Australia ,grid.410692.80000 0001 2105 7653South Western Sydney Local Health District, 1 Elizabeth Street, Liverpool, 2071 Australia
| |
Collapse
|
11
|
Rinaldi I, Amin IF, Shufiyani YM, Dewantara IR, Edina BC, Winston K, Nurrobi YAS. Comparison of the Efficacy and Safety of Rivaroxaban and Enoxaparin as Thromboprophylaxis Agents for Orthopedic Surgery—Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11144070. [PMID: 35887834 PMCID: PMC9315734 DOI: 10.3390/jcm11144070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/28/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
Venous thromboembolism (VTE) is a serious complication that can occur during and after postoperative treatment, including in treatment after orthopedic surgery. The current guidelines for VTE prophylaxis in postoperative patients recommend the use of LMWHs, one of which is enoxaparin. Another recommendation for use in pharmacological VTE prophylaxis is rivaroxaban, which has better efficacy than enoxaparin but a higher bleeding risk. The aim of this systematic review is to provide an update on the profile of rivaroxaban for VTE prophylaxis after orthopedic surgery. PubMed, SCOPUS, EMBASE, and EBSCOhost were searched up until May 2022. The outcome sought was efficacy and safety, described by the incidence of VTE and incidence of bleeding, respectively. Five randomized controlled trials (RCT) were finally included. Rivaroxaban was confirmed to have better efficacy by significantly reducing the risk of VTE and all-cause mortality (RR = 0.38; 95% CI = 0.27–0.54) compared to enoxaparin. However, regarding the safety variable, no significant difference was found between the incidence of major bleeding in rivaroxaban and enoxaparin (RR = 0.97; 95% CI = 0.56–1.68). The results of the analysis show that rivaroxaban has better efficacy than enoxaparin but the same safety profile, so when used, the bleeding of patients should still be monitored.
Collapse
Affiliation(s)
- Ikhwan Rinaldi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusomo National General Hospital, Universitas Indonesia, Jakarta 10430, Indonesia
- Correspondence: ; Tel.: +62-811-177-997
| | - Ihya Fakhrurizal Amin
- Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (I.F.A.); (Y.M.S.); (I.R.D.); (B.C.E.); (K.W.)
| | - Yuli Maulidiya Shufiyani
- Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (I.F.A.); (Y.M.S.); (I.R.D.); (B.C.E.); (K.W.)
| | - Idham Rafly Dewantara
- Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (I.F.A.); (Y.M.S.); (I.R.D.); (B.C.E.); (K.W.)
| | - Brenda Cristie Edina
- Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (I.F.A.); (Y.M.S.); (I.R.D.); (B.C.E.); (K.W.)
| | - Kevin Winston
- Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (I.F.A.); (Y.M.S.); (I.R.D.); (B.C.E.); (K.W.)
- Bhakti Medicare Hospital, Cicurug 43359, Indonesia
| | - Yusuf Aji Samudera Nurrobi
- Pertamina Hospital, Balikpapan 76111, Indonesia;
- Faculty of medicine, Universitas Airlangga, Surabaya 60132, Indonesia
| |
Collapse
|
12
|
Pai FY, Chang WL, Tsai SW, Chen CF, Wu PK, Chen WM. Pharmacological thromboprophylaxis as a risk factor for early periprosthetic joint infection following primary total joint arthroplasty. Sci Rep 2022; 12:10579. [PMID: 35732791 PMCID: PMC9217817 DOI: 10.1038/s41598-022-14749-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/13/2022] [Indexed: 11/09/2022] Open
Abstract
Venous thromboembolism (VTE) prophylaxis has been suggested for patients who underwent total join arthroplasty (TJA). However, the morbidity of surgical site complications (SSC) and periprosthetic joint infection (PJI) has not been well evaluated. We aimed to evaluate the impact of VTE prophylaxis on the risk of early postoperative SSC and PJI in a Taiwanese population. We retrospectively reviewed 7511 patients who underwent primary TJA performed by a single surgeon from 2010 through 2019. We evaluated the rates of SSC and PJI in the early postoperative period (30-day, 90-day) as well as 1-year reoperations. Multivariate regression analysis was used to identify possible risk factors associated with SSC and PJI, including age, sex, WHO classification of weight status, smoking, diabetes mellitus (DM), rheumatoid arthritis(RA), Charlson comorbidity index (CCI), history of VTE, presence of varicose veins, total knee or hip arthroplasty procedure, unilateral or bilateral procedure, or receiving VTE prophylaxis or blood transfusion. The overall 90-day rates of SSC and PJI were 1.1% (N = 80) and 0.2% (N = 16). VTE prophylaxis was a risk factor for 90-day readmission for SSC (aOR: 1.753, 95% CI 1.081-2.842), 90-day readmission for PJI (aOR: 3.267, 95% CI 1.026-10.402) and all 90-day PJI events (aOR: 3.222, 95% CI 1.200-8.656). Other risk factors included DM, underweight, obesity, bilateral TJA procedure, younger age, male sex and RA. Pharmacological thromboprophylaxis appears to be a modifiable risk factor for SSC and PJI in the early postoperative period. The increased infection risk should be carefully weighed in patients who received pharmacological VTE prophylaxis.
Collapse
Affiliation(s)
- Fu-Yuan Pai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Lin Chang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan. .,Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec 2, Shi-Pai Road, Taipei, 112, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| |
Collapse
|
13
|
|
14
|
Yi YH, Gong S, Gong TL, Zhou LY, Hu C, Xu WH. New Oral Anticoagulants for Venous Thromboembolism Prophylaxis in Total Hip and Knee Arthroplasty: A Systematic Review and Network Meta-Analysis. Front Pharmacol 2022; 12:775126. [PMID: 35111051 PMCID: PMC8801787 DOI: 10.3389/fphar.2021.775126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022] Open
Abstract
Background: There is controversy over whether use of new oral anticoagulants (NOACs) associates with increased hemorrhage risk compared with non-NOAC. Meanwhile, determining which NOAC to use remains unclear. We aimed to summarize the evidence about NOACs in venous thromboembolism (VTE) prevention for patients with total hip and knee arthroplasty (THA and TKA). Methods: We searched RCTs assessing NOACs for VTE prophylaxis in adults undergoing THA and TKA in Medline, Embase, and Cochrane up to May 2021. Primary outcomes were VTE [included deep vein thrombosis (DVT) and pulmonary embolism (PE)], major VTE, and major bleeding. The rank probabilities of each treatment were summarized by the surface under the cumulative ranking curve area (SUCRA). Results: 25 RCTs with 42,994 patients were included. Compared with non-NOAC, NOACs were associated with a decreased risk of VTE (RR 0.68; 95% CI 0.55–0.84) and major VTE (RR = 0.52; 95% CI 0.35–0.76). Additionally, rivaroxaban, apixaban, and edoxaban but not dabigatran and betrixaban, did confer a higher efficacy compared with non-NOAC. None of the individual NOACs increased the risk of bleeding, while apixaban and betrixaban were even associated with a decreased risk of bleeding. In the comparison of different NOACs, rivaroxaban was associated with the greatest benefits in VTE (SUCRA = 79.6), DVT (SUCRA = 88.8), and major VTE (SUCRA = 89.9) prevention. Furthermore, subgroup analysis confirmed that NOACs associated with a higher efficacy tendency in patients with follow-up duration <60 days than follow-up duration ≥60 days. Conclusion: Evidence suggests that NOACs exert more benefits on VTE prophylaxis, and none of the individual NOACs increased hemorrhage compared with non-NOAC. Among various NOACs, rivaroxaban is recommended in patients with lower bleeding risk, and apixaban is recommended in patients with higher bleeding risk. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021266890].
Collapse
Affiliation(s)
- Yi-Hu Yi
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Song Gong
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tian-Lun Gong
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling-Yun Zhou
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
| | - Can Hu
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
| | - Wei-Hua Xu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
15
|
Yang HQ, Liu MC, Yin WJ, Zhou LY, Zuo XC. Safety and Efficacy of Low Molecular Weight Heparin for Thromboprophylaxis in the Elderly: A Network Meta-Analysis of Randomized Clinical Trials. Front Pharmacol 2021; 12:783104. [PMID: 34955853 PMCID: PMC8703065 DOI: 10.3389/fphar.2021.783104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Given their changing pathophysiology, elderly patients carry a high risk of embolism and bleeding events; hence, use of appropriate anticoagulants is very important. Low molecular weight heparin (LMWH) is one of the most widely used anticoagulants although LMWHs differ in their anti-Xa, antithrombin, and anticoagulant activities. To date, no study has directly compared the safety and efficacy of different LMWHs in the elderly. We aimed to compare such differences by conducting a network meta-analysis. Methods: We searched the Pubmed, Embase, and Cochrane databases for randomized controlled trials (RCTs) of LMWHs that included patients ≥60 years old up to July 22, 2020. Safety outcomes included venous thromboembolism (VTE) or VTE-related death, deep thrombus embolism, and pulmonary embolism. Safety outcomes were clinically relevant bleeding, major bleeding, minor bleeding, and all-cause death. We calculated relative ratios (RR) and 95% confidence intervals (CI) for all outcomes. The cumulative ranking probabilities (SUCRA) were conducted to rank the comparative effects and safety of all LMWHs. Results: We included 27 RCTs (30,441 elderly), comprising five LMWHs. LMWH was more effective than placebo in preventing VTE or VTE-related death (RR 0.36, 95% CI 0.25–0.53) but less effective than a novel oral anticoagulant (RR 1.59, 95% CI 1.33–1.91) and safer than acenocoumarol regarding risk of clinically relevant bleeding (RR 0.67, 95% CI 0.49–0.90). However, indirect comparison of efficacy and safety of the five LMWHs showed no significant difference in our network analysis, and the subgroup analyses (such as in patients with deep venous thrombosis, cardiac disease, or age >65 years old) supported the results. The SUCRA showed that tinzaparin performed best in preventing VTE or VTE-related death (SUCRA 68.8%, cumulative probability 42.3%) and all-cause death (SUCRA 84.2%, cumulative probability 40.7%), whereas nadroparin was predominant in decreasing the risk of clinically relevant bleeding (SUCRA 84.8%, cumulative probability 77.0%). Conclusions: On present evidence, there are no significant differences in the efficacy and safety of different LMWHs for the elderly. According to the rank probability analysis, nadroparin seems to be safer for the elderly with a high risk of bleeding, whereas tinzaparin is more effective for those with low bleeding risk.
Collapse
Affiliation(s)
- Hui-Qin Yang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Man-Cang Liu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Wen-Jun Yin
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Ling-Yun Zhou
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiao-Cong Zuo
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China.,Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
16
|
Fontalis A, Berry DJ, Shimmin A, Slullitel PA, Buttaro MA, Li C, Malchau H, Haddad FS. Prevention of early complications following total hip replacement. SICOT J 2021; 7:61. [PMID: 34851264 PMCID: PMC8634898 DOI: 10.1051/sicotj/2021060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/29/2021] [Indexed: 01/01/2023] Open
Abstract
Total hip arthroplasty (THA) has been quoted as "the operation of the century", owing to its efficacy and the substantial improvements evidenced with respect to functional patient outcomes and quality of life. However, early postoperative complications are often inevitable, hence it is imperative to take every step to prevent them and minimise morbidity and mortality. This manuscript focuses on the most common early complications following THA, namely venous thromboembolism (VTE), prosthetic joint infection, periprosthetic fracture, instability, and leg length inequality. It aims to outline effective risk stratification strategies and prevention measures that could apply to the wider Orthopaedic community.
Collapse
Affiliation(s)
- Andreas Fontalis
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London NW1 2BU, UK - University College London, Division of Surgery and Interventional Science, Gower Street, London, WC1E 6BT, UK
| | | | - Andrew Shimmin
- Melbourne Orthopaedic Group, Windsor, Victoria 3181, Australia - Monash University, Windsor, Ontario N9B 3P4, Australia
| | - Pablo A Slullitel
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin A Buttaro
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Cao Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, 137 South LiYuShan Road, Urumqi, Xinjiang 830054, China
| | - Henrik Malchau
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London NW1 2BU, UK - University College London, Division of Surgery and Interventional Science, Gower Street, London, WC1E 6BT, UK
| |
Collapse
|
17
|
Alsheikh K, Hilabi A, Aleid A, Alharbi KG, Alangari HS, Alkhamis M, Alzahrani F, AlMadani W. Efficacy and Safety of Thromboprophylaxis Post-Orthopedic Surgery. Cureus 2021; 13:e19691. [PMID: 34934566 PMCID: PMC8684043 DOI: 10.7759/cureus.19691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/29/2022] Open
Abstract
Given the high risk of venous thromboembolism (VTE) post-orthopedic surgery and the vital role of thromboprophylaxis in preventing VTEs, this meta-analysis aimed to assess the efficacy of thromboprophylaxis post major orthopedic surgery and the relevant safety measures. In this review, we conducted a computer-aided search of Google Scholar, PubMed, CINAHL, Cochrane, Medline, and EMBASE databases. We included all published randomized clinical trials (RCTs) that utilized enoxaparin, fondaparinux, dabigatran, rivaroxaban, apixaban, and aspirin for VTE prophylaxis in patients undergoing total hip arthroplasty (THA), hip fracture surgery, and total knee arthroplasty (TKA) based on primary and secondary outcomes. The Cochrane Collaboration tool was used to evaluate the risk of bias. All statistical analyses were performed using Review Manager Software. A total of 23 RCTs were included with a total sample of 48,424 patients and an overall low risk of bias. The efficacy of enoxaparin in preventing VTEs in the TKA group was significantly better than fondaparinux. In the THA group, the efficacy of enoxaparin was significantly better than apixaban. The efficacies of fondaparinux, dabigatran, rivaroxaban, apixaban, and aspirin were comparable to that of enoxaparin in reducing VTE-associated mortality, major bleeding, and adverse events. In conclusion, we found that all included drugs were non-inferior to enoxaparin in VTE-associated mortality, major bleeding, and adverse events.
Collapse
Affiliation(s)
- Khalid Alsheikh
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Division of Orthopedic Surgery, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, SAU
- Department of Orthopedics, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Ahmed Hilabi
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulaziz Aleid
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Khalid G Alharbi
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Hussam S Alangari
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Mohammed Alkhamis
- Department of Orthopedics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Faisal Alzahrani
- Department of Orthopedics, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, SAU
| | - Wedad AlMadani
- Department of Epidemiology and Public Health, General Authority for Statistics, Ministry of Economy and Planning, Riyadh, SAU
| |
Collapse
|
18
|
Ali Hasan M, Azeez Alsaadi M, Tahseen Mehsen J. Effectiveness of apixaban versus enoxaparin in preventing wound complications and deep venous thrombosis following total knee replacement surgery: A retrospective study. Int J Clin Pract 2021; 75:e14552. [PMID: 34145954 DOI: 10.1111/ijcp.14552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Enoxaparin, a thromboprophylactic drug that is widely used for preventing deep venous thrombosis (DVT) and surgical wound complications after total knee replacement surgery, can only be administered subcutaneously. Apixaban, a novel factor Xa inhibitor that could be comparable to enoxaparin, is an oral formulation and thus would be easier to manage. OBJECTIVE To compare the thromboprophylactic effectiveness of apixaban and enoxaparin in patients receiving total knee replacements. METHODS In this retrospective, single-institution study, the records of 200 patients who underwent elective total knee replacement surgery were reviewed. Of those, 120 patients had received enoxaparin 4000 IU daily (initiated 6 hours before surgery), whereas 80 had received apixaban 2.5 mg twice daily (initiated 12 hours after surgery), for 21 days. All patients were examined for major and minor surgical wound complications and DVT incidence during their hospital stay and 7-21 days after surgery. RESULTS No statistically significant differences (P ≥ .005) were found between the apixaban and enoxaparin groups with regard to minor and major surgical wound complications and DVT incidence. Patients in both groups were comparable in terms of age, hospital stay, and required blood transfusion units. Two enoxaparin-treated patients and one apixaban-treated patient developed DVT (1.5%) during the study period. CONCLUSION Oral apixaban is an effective alternative to enoxaparin as a thromboprophylactic drug for patients undergoing elective total knee replacement surgery.
Collapse
|
19
|
Thromboprophylaxis for orthopedic surgery; An updated meta-analysis. Thromb Res 2020; 199:43-53. [PMID: 33422802 DOI: 10.1016/j.thromres.2020.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a serious complication of orthopedic surgery. Low molecular weight heparin (LMWH) has been the standard of care for thromboprophylaxis in this population. However, direct oral anticoagulants (DOACs) are increasingly being used as alternatives. OBJECTIVE To assess the efficacy and safety of DOACs versus LMWH for thromboprophylaxis in orthopedic surgery. METHODS We searched MEDLINE, Embase, and the Cochrane Collaboration Central Register of Controlled Trials from inception until April 2020, for randomized controlled trials (RCTs) comparing DOACs with LMWH for thromboprophylaxis in orthopedic surgery. RESULTS Twenty-five RCTs met inclusion criteria, including 40,438 patients, with a mean age of 68 years and 50% were males. Compared to LMWH, DOACs were associated with a significant reduction of major VTE; defined as the composite events of proximal deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE-related mortality (RR 0.33; 95% CI: 0.20-0.53; P<0.01), and total DVT (RR: 0.59; 95% CI: 0.48-0.73; P<0.01), but not PE (RR 0.81; 95% CI: 0.49-1.34; P=0.42). There was no statistically significant difference between both groups on the incidence of major bleeding (RR 0.99; 95% CI: 0.77-1.27; P=0.92), clinically relevant non-major bleeding (RR 1.04; 95% CI: 0.92-1.17; P=0.52), all-cause mortality (RR 1.06; 95% CI: 0.64-1.76; P=0.83), VTE-related mortality (RR 0.84; 95% CI: 0.40-1.74; P=0.64) and bleeding-related mortality (RR 1.24; 95% CI: 0.30-5.18; P=0.77). CONCLUSION For patients undergoing orthopedic surgery, thromboprophylaxis with DOACs is associated with a significant reduction of major VTE and DVT, compared to LMWH. Safety outcomes were not significantly different between both treatment groups.
Collapse
|
20
|
Anderson DR, Morgano GP, Bennett C, Dentali F, Francis CW, Garcia DA, Kahn SR, Rahman M, Rajasekhar A, Rogers FB, Smythe MA, Tikkinen KAO, Yates AJ, Baldeh T, Balduzzi S, Brożek JL, Ikobaltzeta IE, Johal H, Neumann I, Wiercioch W, Yepes-Nuñez JJ, Schünemann HJ, Dahm P. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv 2019; 3:3898-3944. [PMID: 31794602 PMCID: PMC6963238 DOI: 10.1182/bloodadvances.2019000975] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2). CONCLUSIONS For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.
Collapse
Affiliation(s)
- David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Charles W Francis
- Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | | | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | - Frederick B Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA
| | - Maureen A Smythe
- Department of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI
- Department of Pharmacy Practice, Wayne State University, Detroit, MI
| | - Kari A O Tikkinen
- Department of Urology and
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara Balduzzi
- Department of Diagnostic, Clinical, and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Jan L Brożek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | | | - Herman Johal
- Center for Evidence-Based Orthopaedics, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN; and
- Department of Urology, University of Minnesota, Minneapolis, MN
| |
Collapse
|
21
|
Nadi S, Vreugdenburg TD, Atukorale Y, Ma N, Maddern G, Rovers M. Safety and effectiveness of aspirin and enoxaparin for venous thromboembolism prophylaxis after total hip and knee arthroplasty: a systematic review. ANZ J Surg 2019; 89:1204-1210. [PMID: 30989803 DOI: 10.1111/ans.15122] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/22/2019] [Accepted: 01/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) are at risk of venous thromboembolism (VTE). Australian orthopaedic guidelines recommend aspirin and low-molecular-weight heparin (e.g. enoxaparin) for VTE prophylaxis; however, there is debate in the international literature around the use of aspirin as VTE prophylaxis. This review assesses the risks and benefits of aspirin compared to enoxaparin as VTE prophylaxis for patients undergoing THA or TKA. METHODS A systematic review was conducted to identify relevant randomized controlled trials. Studies comparing enoxaparin, aspirin and/or placebo for VTE prophylaxis in THA or TKA patients were included. Network meta-analysis (NMA) was performed to calculate risk ratios (RRs) and confidence intervals (CIs). Quality appraisal was conducted by assessing risk of bias and the strength of the evidence. RESULTS Nine randomized controlled trials were eligible for inclusion. The NMA found no statistically significant differences for the investigated outcomes: total DVT rates (RR = 1.21, 95% CI 0.86, 1.72), symptomatic pulmonary embolism (PE) rates (RR = 1.02, 95% CI 0.02, 50.86), major haemorrhage (RR = 0.97, 95% CI 0.02, 50.99) and wound complication (RR = 0.73, 95% CI 0.17, 3.20). The occurrence of PE was rare. Due to limited data, sub-group analysis was not possible. The overall quality of evidence in the NMA is considered to be very low. CONCLUSION This review did not find statistically significant differences between aspirin and enoxaparin. Future studies should identify more evidence, particularly for rare outcomes such as PE, as this might help decision-makers to get consensus on the use of aspirin as VTE prophylaxis.
Collapse
Affiliation(s)
- Sinan Nadi
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Thomas D Vreugdenburg
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Yasoba Atukorale
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Ning Ma
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Guy Maddern
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide and The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Maroeska Rovers
- Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
22
|
Factor Xa Inhibitors and Direct Thrombin Inhibitors Versus Low-Molecular-Weight Heparin for Thromboprophylaxis After Total Hip or Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2019; 34:789-800.e6. [PMID: 30685261 DOI: 10.1016/j.arth.2018.11.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 10/31/2018] [Accepted: 11/26/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to perform a meta-analysis to compare outcomes of venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) vs other anticoagulants in patients who received total knee (TKA) or total hip arthroplasty (THA). METHODS MEDLINE, Cochrane, EMBASE, and Google Scholar databases were searched until June 30, 2017 for eligible randomized controlled studies. RESULTS Thirty-two randomized controlled studies were included. LMWH provided better protection against VTE than placebo. In both TKA and THA patients, the rates of VTE were lower with factor Xa inhibitors than LMWH. In THA patients, the rate of deep vein thrombosis (DVT) was lower with factor Xa inhibitors than LMWH. In TKA patients, the rates of VTE and DVT were similar between LMWH and direct thrombin inhibitors. In THA patients, the rate of VTE was lower with direct thrombin inhibitors than with LMWH, while the DVT rates were similar. The pulmonary embolism rates were similar between all 3 classes of drugs in TKA and THR patients, as were the major bleeding rates. Nonmajor and minor bleeding rates were also similar between the 3 drug classes. CONCLUSION LMWH is associated with a higher rate of VTE than factor Xa inhibitors in TKA and THA patients. Direct thrombin inhibitors are associated with a lower rate of VTE in THA patients, but their effectiveness with respect to DVT and pulmonary embolism prophylaxis is similar to that of LMWH in TKA and THA patients.
Collapse
|
23
|
Trivedi NN, Fitzgerald SJ, Schmaier AH, Wera GD. Venous Thromboembolism Chemoprophylaxis in Total Hip and Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2019; 7:e2. [PMID: 30601202 DOI: 10.2106/jbjs.rvw.18.00010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nikunj N Trivedi
- University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Steven J Fitzgerald
- University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alvin H Schmaier
- University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Glenn D Wera
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| |
Collapse
|
24
|
Al-Hillan A, Bajwa RS, Cheema A, Ezeume A, Gor S, Mahida H, Kountz DS. Venous thromboembolism prevention through the use of novel Factor Xa inhibitors. Postgrad Med 2018; 131:89-95. [PMID: 30394165 DOI: 10.1080/00325481.2019.1542925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The risk of a venous thromboembolic event is not limited to the pre-hospital, hospital, or immediate post-hospital period. Because of challenges with data collection, the risk of venous thromboembolism (VTE) up to 3 months post-hospitalization for patients with acute and serious medical problems in the setting of chronic disease and/or risk factors for VTE is probably under reported. The growing acceptance and indications of direct oral anticoagulants (DOACs) now includes an indication for VTE prevention for one of the Factor Xa agents. In this paper, the authors explore the issue of VTE in the extended post-hospital period and strategies to provide protection from these morbid and potentially mortal events with oral anticoagulants.
Collapse
Affiliation(s)
- A Al-Hillan
- a Department of Medicine , Jersey Shore University Medical Center , Neptune , NJ , USA
| | - R S Bajwa
- a Department of Medicine , Jersey Shore University Medical Center , Neptune , NJ , USA
| | - A Cheema
- a Department of Medicine , Jersey Shore University Medical Center , Neptune , NJ , USA
| | - A Ezeume
- a Department of Medicine , Jersey Shore University Medical Center , Neptune , NJ , USA
| | - S Gor
- a Department of Medicine , Jersey Shore University Medical Center , Neptune , NJ , USA
| | - H Mahida
- a Department of Medicine , Jersey Shore University Medical Center , Neptune , NJ , USA
| | - D S Kountz
- a Department of Medicine , Jersey Shore University Medical Center , Neptune , NJ , USA
| |
Collapse
|
25
|
Trends in Deep Vein Thrombosis Prophylaxis and Deep Vein Thrombosis Rates After Total Hip and Knee Arthroplasty. J Am Acad Orthop Surg 2018; 26:698-705. [PMID: 30153117 DOI: 10.5435/jaaos-d-17-00235] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) are at high risk of deep vein thrombosis (DVT) postoperatively, necessitating the use of prophylaxis medications. This investigation used a large claims database to evaluate trends in postoperative DVT prophylaxis and rates of DVT within 6 months after THA or TKA. METHODS Truven Health MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases were reviewed from 2004 to 2013 for patients who underwent THA or TKA. Data were collected on patient age, sex, Charlson Comorbidity Index, and hypercoagulability diagnoses. Postoperative medication claims were reviewed for prescribed aspirin, warfarin, enoxaparin, fondaparinux, rivaroxaban, and dabigatran. RESULTS A total of 369,483 patients were included in the analysis, of which 239,949 patients had prescription medication claims. Warfarin was the most commonly prescribed anticoagulant. Patients with a hypercoagulable diagnosis had markedly more DVTs within 6 months after THA or TKA. More patients with a hypercoagulable diagnosis were treated with warfarin or lovenox than other types of anticoagulants. A multivariate regression analysis was performed, showing that patients prescribed aspirin, fondaparinux, and rivaroxaban were markedly less likely than those prescribed warfarin or enoxaparin to have a DVT within 6 months after THA or TKA. CONCLUSION After THA and TKA, warfarin is the most commonly prescribed prophylaxis. Patients with hypercoagulability diagnoses are at a higher risk of postoperative DVT. The likelihood of DVT within 6 months of THA and TKA was markedly higher in patients treated with warfarin and lovenox and markedly lower in those treated with aspirin, fondaparinux, and rivaroxaban. LEVEL OF EVIDENCE Level III.
Collapse
|
26
|
Lu X, Lin J. Low molecular weight heparin versus other anti-thrombotic agents for prevention of venous thromboembolic events after total hip or total knee replacement surgery: a systematic review and meta-analysis. BMC Musculoskelet Disord 2018; 19:322. [PMID: 30193575 PMCID: PMC6129001 DOI: 10.1186/s12891-018-2215-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 08/01/2018] [Indexed: 01/23/2023] Open
Abstract
Background Venous thromboembolism (VTE) is an important complication following total hip replacement (THR) and total knee replacement (TKR) surgeries. Aim of this study was to comprehensively compare the clinical outcomes of low-molecular-weight heparin (LMWH) with other anticoagulants in patients who underwent TKR or THR surgery. Methods Medline, Cochrane, EMBASE, and Google Scholar databases were searched for eligible randomized controlled studies (RCTs) published before June 30, 2017. Meta-analyses of odds ratios were performed along with subgroup and sensitivity analyses. Results Twenty-one RCTs were included. In comparison with placebo, LMWH treatment was associated with a lower risk of VTE and deep vein thrombosis (DVT) (P values < 0.001) but similar risk of pulmonary embolism (PE) (P = 0.227) in THR subjects. Compared to factor Xa inhibitors, LMWH treatment was associated with higher risk of VTE in TKR subjects (P < 0.001), and higher DVT risk (P < 0.001) but similar risk of PE and major bleeding in both THR and TKR. The risk of either VTE, DVT, PE, or major bleeding was similar between LMWH and direct thrombin inhibitors in both THR and TKR, but major bleeding was lower with LMWH in patients who underwent THR (P = 0.048). Conclusion In comparison with factor Xa inhibitors, LMWH may have higher risk of VTE and DVT, whereas compared to direct thrombin inhibitors, LMWH may have lower risk of major bleeding after THR or TKR. Electronic supplementary material The online version of this article (10.1186/s12891-018-2215-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Xin Lu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jin Lin
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|