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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.
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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
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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.
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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
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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).
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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
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Wong SYW, Ler FLS, Sultana R, Bin Abd Razak HR. What is the best prophylaxis against venous thromboembolism in Asians following total knee arthroplasty? A systematic review and network meta-analysis. Knee Surg Relat Res 2022; 34:37. [PMID: 35964142 PMCID: PMC9375282 DOI: 10.1186/s43019-022-00166-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 07/27/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Purpose
Asians have a low venous thromboembolism (VTE) incidence following total knee arthroplasty (TKA). This systematic review and network meta-analysis was conducted to evaluate the best prophylaxis against VTE in Asians following total knee arthroplasty in current literature.
Materials and Methods
A systematic search of PubMed, Embase and CINAHL was conducted in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Prophylaxis types were separated into low-molecular-weight heparin (LMWH), novel oral anti-coagulants (NOAC), mechanical-only prophylaxis (MOP) and no prophylaxis (NP). The primary outcome was VTE incidence, grouped according to diagnosis modality (ultrasound, venography, clinical). The secondary outcome was bleeding incidence, grouped into minor and major bleeding.
Results
Fourteen eligible articles, totalling 4259 patients, were pooled with the following significant results: NOACs had lower venography-diagnosed VTE incidence than LMWH (12.77%, p = 0.02) and NP (20.64, p < 0.001). MOP had lower venography-diagnosed VTE incidence than LMWH (23.72%, p < 0.001), NOACs (10.95%, p < 0.001) and NP (31.59%, p < 0.001) but, interestingly, a statistically higher ultrasound-diagnosed VTE incidence than LMWH (6.56%, p = 0.024) and NP (4.88%, p = 0.026). No significant differences were observed between prophylaxis types for symptomatic VTE, pulmonary embolism (PE) or death. LMWH and NOACs had a higher minor bleeding incidence than NP (11.71%, p < 0.001 and 6.33%, p < 0.02, respectively). No significant differences were observed between prophylaxis types for major bleeding incidence.
Conclusion
NOACs are a superior form of chemoprophylaxis, compared with LMWH, in reducing venography-diagnosed VTE incidence with no added bleeding incidence. However, routine chemoprophylaxis may not be required as LMWH and NOACs do not appear to reduce symptomatic VTE incidence compared with MOP and NP with an increased minor bleeding incidence. Mechanical prophylaxis in the form of graduated compression stockings or intermittent pneumatic compression should be routinely considered with significantly lower rates of venography-diagnosed VTE compared with NP. On the basis of current evidence, we recommend an individualised approach to select the most appropriate prophylaxis type.
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Chua CXK, Tan JHI, Bin Abd Razak HR. Enoxaparin Versus Direct Oral Anticoagulants for Venous Thromboembolism in Asians Undergoing Total Knee Arthroplasty: A Meta-Analysis and Systematic Review. J Arthroplasty 2022; 37:593-600.e1. [PMID: 34843908 DOI: 10.1016/j.arth.2021.11.030] [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: 08/11/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The introduction of direct oral anticoagulants (DOACs) shows promise for their role as a chemoprophylaxis agent after total knee arthroplasty (TKA) for the prevention of venous thromboembolism (VTE). However, existing studies are largely based on Western populations that do not account for the different risk profiles and lower rates of VTE in Asians. This systematic review and meta-analysis aimed to evaluate the efficacy of DOACs compared with enoxaparin in an Asian-based population study. METHODS The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that compared outcomes between enoxaparin and DOACs as VTE prophylaxis after TKA in the Asian population were included. RESULTS Five studies with 121,153 patients were included. DOACs demonstrated a convincing benefit over enoxaparin in overall VTE prevention (odds ratio [OR] = 0.42, 95% confidence interval [CI]: 0.24-0.74). However, although the OR trended in favor of DOACs for the reduction of deep vein thrombosis events (OR = 0.54, 95% CI: 0.20-1.48) and pulmonary embolism (OR = 0.75, 95% CI: 0.07-8.20), statistical significance was not reached. In terms of bleeding complications, both arms had similar rates of major (0.91% vs 0.20%), clinically relevant nonmajor (3.28% vs 2.94%), and minor bleeding complications (12.8 vs 13.3%). A nonsignificance advantage of enoxaparin over DOACs was revealed in the OR for major bleeding (OR = 3.17; 95% CI: 0.81-12.43), whereas DOACs were favored to reduce risk of clinically relevant nonmajor (OR = 0.82; 95% CI: 0.01-91.51) and minor bleeding (OR = 0.76; 95% CI: 0.11-5.33). CONCLUSION DOACs confer a significantly reduced rate of overall VTE compared with enoxaparin in Asians after TKA. No significant differences in deep vein thrombosis, pulmonary embolism, and rates of bleeding complications exist.
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Affiliation(s)
- Chen Xi Kasia Chua
- National University Hospital Sports Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Joelle Hwee Inn Tan
- National University Hospital Sports Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
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7
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Feng W, Wang X, Huang D, Lu A. Ranking the efficacy of anticoagulants for the prevention of venous thromboembolism after total hip or knee arthroplasty: A systematic review and a network meta-analysis. Pharmacol Res 2021; 166:105438. [PMID: 33540046 DOI: 10.1016/j.phrs.2021.105438] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/16/2021] [Accepted: 01/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anticoagulants are essential in the prevention of venous thromboembolism. However, the effectiveness and safety of different anticoagulants have always been controversial. Therefore, we aimed to expand the sample of anticoagulant results and rank the efficacy and safety of 19 anticoagulants in the prevention of venous thromboembolism when total knee or total hip arthroplasty procedure is performed. METHODS A systematic review and network meta-analysis of randomized trials of adult patients undergoing total hip or knee arthroplasty were conducted. The trials were identified from PubMed, Web of Science, Cochrane Library, and Embase databases, in which anticoagulants were used as interventions randomized controlled trial. The incidence of venous embolism and bleeding are the key outcomes of assessing the efficacy of intervention drugs. We used the Physical Therapy Evidence Database (PEDro) to assess risk bias and used pairwise comparison and network meta-analysis with random effects to estimate the summary relative risk. The study has been registered with PROSPERO, number CRD42020200747. RESULTS From the 4083 identified manuscripts, 45,067 participants from 53 randomized trials were included in the analysis and randomly assigned to 19 anticoagulants. With Enoxaparin as a control, Rivaroxaban (risk difference 0.07, 95 % credible interval 0.06 to 0.08), Edoxaban (RD 0.09, 95 % CrI 0.08 to 0.11), and Apixaban (RD 0.05, 95 % CrI 0.04 to 0.06) had the best effect in preventing VTE. However, in terms of comprehensive bleeding rate, Apixaban, Edoxaban, and Darexaban were the most effective and stable. Although effective in preventing VTE, bleeding remains relatively high in Rivaroxaban. Enoxaparin is low-molecular-weight heparin that is widely used in clinics, and although its overall efficacy is not the best, its efficacy and safety are very stable. CONCLUSION According to the available data, Apixaban, Edoxaban, and Darexaban are better than any anticoagulants in the prevention of VTE and bleeding during total knee or total hip arthroplasty. In our study, Fondaparinux, Eribaxaban, Dalteparin, Betrixaban, Bemiparin, Reviparin, Acenocoumarol, and Tinzaparin were scarce in the included studies, therefore, more evidence is needed to prove their efficacy and safety.
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Affiliation(s)
- Weili Feng
- Orthopaedics Department, Affiliated Xiaolan Hospital, Southern Medical University, No. 65, Jucheng Rd. Xiaolan Dist, 528415, Zhongshan, Guangdong Prov., PR China.
| | - Xiaoping Wang
- Orthopaedics Department, Affiliated Xiaolan Hospital, Southern Medical University, No. 65, Jucheng Rd. Xiaolan Dist, 528415, Zhongshan, Guangdong Prov., PR China.
| | - Daoqiang Huang
- Orthopaedics Department, Affiliated Xiaolan Hospital, Southern Medical University, No. 65, Jucheng Rd. Xiaolan Dist, 528415, Zhongshan, Guangdong Prov., PR China.
| | - Anqi Lu
- School of Physical Education and Training, Shanghai University of Sport, No.650, Qingyuanhuan Rd., 200438, Shanghai Municipality, PR China.
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Weng XS, Liu J, Wu D. Chinese Survey on Enhanced Recovery after Surgery and Thromboprophylaxis Following Arthroplasty. Orthop Surg 2020; 12:900-906. [PMID: 32489003 PMCID: PMC7307227 DOI: 10.1111/os.12705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/13/2020] [Accepted: 04/25/2020] [Indexed: 12/28/2022] Open
Abstract
Objective To examine the current perspectives of enhanced recovery after surgery (ERAS) and the clinical practice applications of important ERAS principles among Chinese orthopaedic surgeons. Methods This was a cross‐sectional study using an online survey that was completed between November and December 2018. A 16‐item online questionnaire regarding the experiences of ERAS, perceptions of methods, and durations and concerns of venous thromboembolism (VTE) prophylaxis was sent to 2000 orthopaedic surgeons nationwide, and 1720 (86%) surgeons responded. Statistical analyses were conducted to assess all respondents' results and to compare differences among subgroups that were stratified according to city and hospital level, as well as their professional title. Results According to the results of the survey, ERAS awareness was high (65.1%) and most surgeons recognized the importance of thromboprophylaxis. However, the timing of ERAS was not consistent, with 22.8%, 31.9%, and 37.7% of surgeons choosing to initiate pharmaceutical prophylaxis within <6 h, 6–12 h, and 12–24 h after surgery, respectively. Low‐molecular‐weight heparin was mainly selected during hospitalization, and new oral anticoagulants (NOACs) were the first choice after discharge. Regarding postoperative antithrombotic therapy, particularly when combined with analgesics, the potential bleeding risk was mostly considered (80.0%)Tranexamic acid was believed to have no effect on the timing of NOAC therapy initiation (56.2%). Most of the above outcomes were influenced by the hospital level and professional title of the surgeon. Surgeons who had higher awareness on ERAS and better adhered to the guidelines were from higher‐level hospitals as well as had more advanced professional titles. City level partly might influence their practice but not impact surgeons' awareness. Conclusions The awareness and perception of the concept of ERAS and prophylactic antithrombotic regimens remain different among Chinese orthopaedic surgeons in different level cities and with various professional titles. Continuing medical educations (CME) on VTE prophylaxis is needed for improving the quality of health care in China.
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Affiliation(s)
- Xi-Sheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Juan Liu
- Medical Affairs Department, Pfizer Inc, Shanghai, China
| | - Duo Wu
- Medical Affairs Department, Pfizer Inc, Guangzhou, China
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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.
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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
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Loh JLM, Chan S, Wong KL, de Mel S, Yap ES. Chemoprophylaxis in addition to mechanical prophylaxis after total knee arthroplasty surgery does not reduce the incidence of venous thromboembolism. Thromb J 2019; 17:9. [PMID: 31249474 PMCID: PMC6584992 DOI: 10.1186/s12959-019-0200-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) of the lower limbs is an important complication post total knee arthroplasty (TKA). Current guidelines recommend routine chemical prophylaxis to all patients undergoing this procedure but this is rarely done in Asia as it is believed that Asians have a lower risk of VTE. However, recent evidence suggests otherwise. AIMS We evaluated the incidence of DVT after TKA in a multi-ethnic Asian population with and without pharmacological prophylaxis, as well as the management and outcome of patients with post-operative DVTs. METHODS We conducted a retrospective study of consecutive patients who underwent TKA in our hospital from 1st January 2004 to 30th December 2014. All patients were on mechanical thromboprophylaxis via calf pumps after TKA with a postoperative day 3 to 5 doppler ultrasound (DUS) of bilateral lower limbs. 2258 (80.7%) patients did not receive additional chemoprophylaxis, while 540 (19.3%) received chemoprophylaxis on top of mechanical thromboprophylaxis. All patients who received chemoprophylaxis were administered the drug until they were ambulating, with a median administration duration of 6 days. Patients were followed up for a period of 3 months for recurrence of DVTs and 24 months for postoperative outcome scores. RESULTS Two thousand nine hundred seventy-eight patients had DUS of the lower limbs with 134 diagnosed with DVT giving an incidence of 4.5%. Six of these patients had concurrent PEs. There were 26 (19.4%) proximal DVTs and 108 (80.6%) distal DVTs. After 3 months of follow up, no additional VTE occurred. None of the DVTs or PEs progressed.All DVTs with accompanying PE were proximal. 102 out of 2200 patients (4.6%) without chemoprophylaxis developed DVT as compared to 32 out of 540 patients (5.9%) with chemoprophylaxis, which was not statistically significant (p = 0.13). 19 (0.8%) proximal and 83 (3.8%) distal DVT developed in the patient group without chemoprophylaxis while 4 (0.7%) proximal and 28 (5.2%) distal DVT developed in the patient group with (p = 0.62). Comparison of the incidence of PEs between the two groups, revealed a similar incidence with 5 out of 2200 patients (0.2%) without chemoprophylaxis developing PE as compared to 1 out of 540 patients (0.2%) with chemoprophylaxis (p = 0.87).In addition, patients with chemoprophylaxis showed an association with higher post-operative outcome scores such as post op 6 months SF36 (PCS), post op 12 months SF36 (PCS), post op 12 months SF36 (MCS), post op 24 months SF36 (MCS) and post op 24 months WOMAC. CONCLUSION In one of the largest Asian studies specifically investigating the incidence of DVT after TKA, we found that the incidence is low at 4.5%. This is in contrast to recent studies that showed higher post-operative VTE rates similar to Western populations. In addition, patients who were administered chemoprophylaxis did not have a statistically significant difference in incidence of VTE although it did show a correlation with higher post-operative outcome scores which may indicate better function. This was seen in functional outcome scores such as post op 6 months SF36 (PCS), post op 12 months SF36 (PCS), post op 12 months SF36 (MCS), post op 24 months SF36 (MCS) and post op 24 months WOMAC.
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Affiliation(s)
- Jing Loong Moses Loh
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Academia, Level 4, Singapore, 169865 Singapore
| | - Stephrene Chan
- Department of Haematology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Keng Lin Wong
- Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Sanjay de Mel
- Department of Hematology-Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Eng Soo Yap
- Department of Hematology-Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
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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.
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Dimitropoulos G, Rahim SMZ, Moss AS, Lip GYH. New anticoagulants for venous thromboembolism and atrial fibrillation: what the future holds. Expert Opin Investig Drugs 2017; 27:71-86. [DOI: 10.1080/13543784.2018.1416090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Gerasimos Dimitropoulos
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Cardiology Department, City Hospital, Birmingham, UK
| | - S. M. Zubair Rahim
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Cardiology Department, City Hospital, Birmingham, UK
| | - Alexandra Sophie Moss
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Cardiology Department, City Hospital, Birmingham, UK
| | - Gregory Y. H. Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Agnelli G, Gallus A, Lassen M, Prins M, Renfurm R, Kashiwa M, Turpie A, Eriksson B. Darexaban (YM150) versus enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a randomised phase IIb dose confirmation study (ONYX-3). Thromb Haemost 2017; 111:213-25. [DOI: 10.1160/th13-04-0296] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 09/13/2013] [Indexed: 01/23/2023]
Abstract
SummaryThis double-blind, double-dummy, randomised, phase IIb study (NCT00902928) evaluated different dosing regimens of darexaban compared with enoxaparin (randomised 1:1:1:1:1 to 15 mg twice daily [bid], 30 mg once daily [qd], 30 mg bid or 60 mg qd or enoxaparin 40 mg qd) in patients undergoing elective total hip arthroplasty. Patients, investigators, pharmacists and sponsor were all blinded to treatment allocation. Darexaban administration started 6-10 hours (h) post-surgery. Enoxaparin 40 mg qd administration started 12 ± 2 h before surgery. Treatment continued for 35 days. Bilateral venography was performed on Day 10 ± 2. The primary efficacy outcome was total VTEs (composite of proximal/distal deep-vein thrombosis, pulmonary embolism) or death, at Day 12. Total VTE rates were similar across all groups. There was no apparent difference in efficacy between onceand twice-daily darexaban (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.71–1.42; p=0.988), or total daily dose (30 mg/day vs 60 mg/day; OR 0.81; 95% CI 0.57–1.15; p=0.244). There was no significant difference in major and/or clinically relevant non-major bleeding between darexaban qd or bid, or between total daily doses of 30 mg or 60 mg, and also for any dosing regimen of darexaban vs enoxaparin. Darexaban was well tolerated, without signs of liver toxicity. In conclusion, darexaban, administered qd or bid, and at total daily doses of 30 mg or 60 mg, appears to be effective for VTE prevention and was well tolerated. Data suggest no significant differences between a once- or twice-daily dosing regimen.
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Rao P, Burkart T. Advances in oral anticoagulation therapy – What's in the pipeline? Blood Rev 2017; 31:205-211. [DOI: 10.1016/j.blre.2017.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/02/2017] [Indexed: 01/14/2023]
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Kapoor A, Ellis A, Shaffer N, Gurwitz J, Chandramohan A, Saulino J, Ishak A, Okubanjo T, Michota F, Hylek E, Trikalinos TA. Comparative effectiveness of venous thromboembolism prophylaxis options for the patient undergoing total hip and knee replacement: a network meta-analysis. J Thromb Haemost 2017; 15:284-294. [PMID: 28102615 PMCID: PMC5305416 DOI: 10.1111/jth.13566] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 10/24/2016] [Indexed: 12/20/2022]
Abstract
Essentials Despite trial data, guidelines have not endorsed direct oral Xa inhibitors above other options. We provide profiles of venous thromboembolism and hemorrhage risk for 12 options. Direct oral Xa inhibitors had a favorable profile compared with low-molecular-weight heparin. Other options did not have favorable profiles compared with low-molecular-weight heparin. SUMMARY Background There are numerous trials and several meta-analyses comparing venous thromboembolism (VTE) prophylaxis options after total hip and knee replacement (THR and TKR). None have included simultaneous comparison of new with older options. Objective To measure simultaneously the relative risk of VTE and hemorrhage for 12 prophylaxis options. Methods We abstracted VTE and hemorrhage information from randomized controlled trials published between January 1990 and June 2016 comparing 12 prophylaxis options. We then constructed networks to compute the relative risk for each option, relative to once-daily dosing with low-molecular-weight heparin (LMWH) Low. Results Main: Relative to LMWH Low, direct oral Xa inhibitors had the lowest risk of total deep vein thrombosis (DVT)-asymptomatic and symptomatic- (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.35-0.57), translating to 53-139 fewer DVTs per 1000 patients. Vitamin K antagonists (VKAs) titrated to International Normalized Ratio [INR] 2-3 predicted 56% more DVT events (OR, 1.56; 95% CI, 1.14-2.14). Aspirin performed similarly (OR, 0.80; 95% CI, 0.34-1.86), although small numbers prohibit firm conclusions. Direct oral Xa inhibitors did not lead to significantly more bleeding (OR, 1.21; 95% CI, 0.79-1.90). Secondary: Relative to LMWH Low, direct oral Xa inhibitors prevented 4-fold more symptomatic DVTs (OR, 0.25; 95% CI, 0.13-0.47). Conclusions Relative to LMWH Low, direct oral Xa inhibitors had a more favorable profile of VTE and hemorrhage risk, whereas VKAs had a less favorable profile. The profile of other agents was not more or less favorable. Clinicians should consider these profiles when selecting prophylaxis options.
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Affiliation(s)
- Alok Kapoor
- University of Massachusetts Medical School, Biotech 1, Suite 100, Worcester, MA 01605
- Meyers Primary Care Institute, 630 Plantation St, Worcester, MA, USA, 01605
- Boston University School of Medicine, 72 E Concord St, Boston, MA, USA, 02118
| | - Alexandra Ellis
- Brown University School of Public Health, 121 S Main St, Providence, RI, USA, 02903
| | - Nicholas Shaffer
- University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA, 78229
| | - Jerry Gurwitz
- Meyers Primary Care Institute, 630 Plantation St, Worcester, MA, USA, 01605
- University of Massachusetts Medical School, 55 North Lake Avenue, Worcester, MA, USA, 01655
| | | | - Justin Saulino
- Boston Medical Center, 840 Harrison Ave, Boston, MA, USA, 02118
- Biogen Idec, 14 Cambridge Center, Cambridge, MA, USA, 02412
| | - Anthony Ishak
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, USA, 02215
| | - Temitayo Okubanjo
- Cox Health Department of Pharmacy, 1423 N Jefferson Ave, Springfield, MO, USA, 65802
| | | | - Elaine Hylek
- Boston University School of Medicine, 72 E Concord St, Boston, MA, USA, 02118
| | - Thomas A Trikalinos
- Brown University School of Public Health, 121 S Main St, Providence, RI, USA, 02903
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16
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Anticoagulant therapy for venous thromboembolism prophylaxis in orthopaedic surgery in Japan: The evolving role of NOACs. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Feng W, Wu K, Liu Z, Kong G, Deng Z, Chen S, Wu Y, Chen M, Liu S, Wang H. Oral direct factor Xa inhibitor versus enoxaparin for thromboprophylaxis after hip or knee arthroplasty: Systemic review, traditional meta-analysis, dose-response meta-analysis and network meta-analysis. Thromb Res 2015; 136:1133-44. [PMID: 26498222 DOI: 10.1016/j.thromres.2015.10.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/01/2015] [Accepted: 10/05/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To analyze the efficacy and safety of direct factor Xa inhibitors for thromboprophylaxis after total hip or knee replacement. To delineate the dose response effect of direct factor Xa inhibitors. To compare the efficacy between any two direct factor Xa inhibitors. DESIGN Systemic review, traditional meta-analysis, dose-response meta-analysis and network meta-analysis. DATA SOURCE PubMed, EMBASE and Cochrane Library. STUDY SELECTION Randomized controlled trials of rivaroxaban, apixaban, betrixaban, darexaban and edoxaban were compared with enoxaparin for thromboprophylaxis after total hip or knee replacement. Two reviewers independently checked the quality of RCTs. Another two investigators independently extracted data. The primary efficacy outcomes (composite of deep venous thrombosis, non-fatal pulmonary embolism and death of all causes) and the primary bleeding outcomes (major bleeding and non-major but clinically relevant bleeding) were summarized for meta-analysis. Stata software was used for traditional meta-analysis and dose-response meta-analysis, and Winbugs software was used for network meta-analysis. RESULTS Twenty trials with 38,507 subjects in the intention-to-treat population were included. Compared with enoxaparin, the risk of total venous thromboembolism was lower with rivaroxaban (relative risk 0.70, 95% confidence interval 0.60 to 0.81), apixaban (0.62, 0.47 to 0.81), and edoxaban (0.62, 0.39 to 0.97) and similar to darexaban (0.96, 0.84 to 1.11) and betrixaban (1.28, 0.97 to 1.68). Compared with enoxaparin, the risk of major or clinically relevant non-major bleeding was higher with rivaroxaban (1.52, 1.14 to 2.02), lower with betrixaban (0.34, 0.14 to 0.84) and similar to apixaban (0.88, 0.73 to 1.05), darexaban (0.85, 0.66 to 1.09) or edoxaban (1.30, 0.72 to 2.33). The risk of major and clinically relevant non-major bleeding of rivaroxaban had a linear relationship with its treatment doses; the risk of total venous thromboembolism of betrixaban and darexaban had linear relationships with their respective treatment doses. There was no linear nor non-liner relationships between the effect of apixaban and its treatment dose. The ranking of total venous thromboembolism risk from low to high was: rivaroxaban, apixaban, edoxaban, enoxaparin, darexaban, and betrixaban. The ranking of major and clinically relevant non-major bleeding from low to high was: betrixaban, enoxaparin, darexaban, edoxaban, apixaban, and rivaroxaban. CONCLUSIONS Direct oral factor Xa inhibitors are more effective to prevent venous thromboembolism after total hip or knee replacement. Their anticoagulant effect was not necessarily compromised with a higher bleeding risk. Rivaroxaban, apixaban and edoxaban showed a better anticoagulant effect, as compared with enoxaparin. Rivaroxaban had a higher bleeding rate, while apixaban and edoxaban did not show significantly higher bleeding risks.
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Affiliation(s)
- Weili Feng
- Orthopedics Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People's Republic of China
| | - Kezhou Wu
- Orthopedics Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People's Republic of China
| | - Zhaoyong Liu
- Orthopedics Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People's Republic of China
| | - Gengbin Kong
- Orthopedics Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People's Republic of China
| | - Zhihua Deng
- Orthopedics Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People's Republic of China
| | - Shubiao Chen
- Orthopedics Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People's Republic of China
| | - Yudan Wu
- Orthopedics Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People's Republic of China
| | - Mengmeng Chen
- Orthopedics Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People's Republic of China
| | - Shuo Liu
- Orthopedics Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People's Republic of China
| | - Hu Wang
- Orthopedics Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People's Republic of China.
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18
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Blann A. Nonvitamin K antagonist oral anticoagulants (NOACs): the tide continues to come in. Vasc Health Risk Manag 2015; 11:489-92. [PMID: 26316773 PMCID: PMC4548753 DOI: 10.2147/vhrm.s89736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Andrew Blann
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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Lip GYH, Halperin JL, Petersen P, Rodgers GM, Pall D, Renfurm RW. A Phase II, double-blind, randomized, parallel group, dose-finding study of the safety and tolerability of darexaban compared with warfarin in patients with non-valvular atrial fibrillation: the oral factor Xa inhibitor for prophylaxis of stroke in atrial fibrillation study 2 (OPAL-2). J Thromb Haemost 2015; 13:1405-13. [PMID: 26052866 DOI: 10.1111/jth.13025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 05/28/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Darexaban (YM150) is a novel oral anticoagulant that directly inhibits factor Xa. OBJECTIVES To investigate the optimal daily dose regimen of YM150 in subjects with non-valvular atrial fibrillation (NVAF). METHODS In this multicenter, double-blind, double-dummy, randomized, parallel-group, dose-confirmation study (NCT00938730), patients with NVAF were randomized to darexaban 15 mg bid, 30 mg qd, 30 mg bid, 60 mg qd, 60 mg bid or 120 mg qd, or warfarin qd. The primary endpoint was the incidence of adjudicated major and/or clinically relevant non-major bleeding events. Secondary endpoints included efficacy, pharmacodynamics, safety and tolerability. RESULTS A total of 1297 patients were randomized and finally included in the trial (median age, 66 [range 30-89] years; 68.8% male): 981 completed treatment for a median of 28 weeks (interquartile range, 24-36). At daily doses of 30-60 mg, darexaban bid resulted in fewer bleeding events than darexaban qd. For darexaban 120 mg, the bid regimen produced more bleeding events than the qd regimen. Although few efficacy endpoints occurred, these decreased with increasing daily darexaban dose. Darexaban decreased plasma D-dimer levels (index of thrombogenesis) after 4 weeks of treatment by 21.5-33.8% compared with baseline, which was comparable with warfarin at the higher darexaban doses. Darexaban was well tolerated with no liver toxicity. CONCLUSIONS In this Phase II study in patients with NVAF, a lower bleeding rate was observed in the 120 mg daily darexaban group compared with warfarin with a reduction in plasma D-dimer as marker for hemostasis. Further investigation of the optimal dose of darexaban for the prevention of stroke in patients with NVAF would need to be considered.
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Affiliation(s)
- G Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - J L Halperin
- The Zena and Michael A. Wiener Cardiovascular Institute, The Marie Josée and Henry R. Kravis Centre for Cardiovascular Health, Mount Sinai Medical Centre, New York, NY, USA
| | - P Petersen
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - D Pall
- Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - R W Renfurm
- Astellas Pharma Global Development, Leiden, the Netherlands
- Department of Cardiology C5-P, Leiden University Medical Center, Leiden, the Netherlands
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Kadokura T, Kashiwa M, Groenendaal D, Heeringa M, Mol R, Verheggen F, Garcia-Hernandez A, Onkels H. Clinical pharmacokinetics, pharmacodynamics, safety and tolerability of darexaban, an oral direct factor Xa inhibitor, in healthy Caucasian and Japanese subjects. Biopharm Drug Dispos 2013; 34:431-41. [DOI: 10.1002/bdd.1858] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 07/21/2013] [Accepted: 08/03/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Takeshi Kadokura
- Astellas Pharma Inc; 3-17-1, Hasune, Itabashi-ku; Tokyo; 174-8612; Japan
| | - Makoto Kashiwa
- Astellas Pharma Inc; 3-17-1, Hasune, Itabashi-ku; Tokyo; 174-8612; Japan
| | - Dorien Groenendaal
- Astellas Pharma Global Development Europe; Sylviusweg 62, PO Box 344; 2300 AH; Leiden; the Netherlands
| | - Marten Heeringa
- Astellas Pharma Global Development Europe; Sylviusweg 62, PO Box 344; 2300 AH; Leiden; the Netherlands
| | - Roelof Mol
- Astellas Pharma Global Development Europe; Sylviusweg 62, PO Box 344; 2300 AH; Leiden; the Netherlands
| | - Frank Verheggen
- Astellas Pharma Global Development Europe; Sylviusweg 62, PO Box 344; 2300 AH; Leiden; the Netherlands
| | - Alberto Garcia-Hernandez
- Astellas Pharma Global Development Europe; Sylviusweg 62, PO Box 344; 2300 AH; Leiden; the Netherlands
| | - Hartmut Onkels
- Astellas Pharma Global Development Europe; Sylviusweg 62, PO Box 344; 2300 AH; Leiden; the Netherlands
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21
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Kadokura T, Groenendaal D, Heeringa M, Mol R, Verheggen F, Garcia-Hernandez A, Onkels H. Darexaban (YM150), an oral direct factor Xa inhibitor, has no effect on the pharmacokinetics of digoxin. Eur J Drug Metab Pharmacokinet 2013; 39:1-9. [PMID: 23754514 DOI: 10.1007/s13318-013-0141-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 05/23/2013] [Indexed: 01/27/2023]
Abstract
To investigate the impact of the direct Factor Xa inhibitor darexaban administered in a modified-release formulation (darexaban-MR) on the pharmacokinetic (PK) profile of digoxin. In this Phase I, randomized, double-blind, two-period crossover study (8 days for each treatment, 10 days washout), 24 healthy subjects received darexaban-MR 120 mg once/day (qd) + digoxin 0.25 mg qd in one treatment period, and placebo + digoxin 0.25 mg qd in the other treatment period. Blood for PK assessment of digoxin and darexaban was obtained in serial profile on day 8, as well as pre-dose on day 6-7; urinary PK samples were obtained up to 24 h after the last dose on day 8. A lack of interaction was determined if 90 % confidence intervals (CIs) for the geometric mean ratios (GMR) of digoxin C max,ss and AUC0-24h,ss with and without darexaban-MR co-administration were within 0.80-1.25 limits. Pharmacodynamic activity was assessed by international normalized ratio and activated partial thromboplastin time. Twenty-three subjects completed the study. The GMR (90 % CI) for C max,ss and AUC0-24h,ss of digoxin plus darexaban versus digoxin plus placebo was 1.03 (90 % CI: 0.94-1.12) and 1.11 (90 % CI: 1.05-1.17), respectively. The 90 % CI for the GMRs fell within the limits of 0.80-1.25, indicating a lack of drug-drug interaction. Co-administration of digoxin with darexaban-MR was well tolerated, with no unexpected treatment-emergent adverse events or safety concerns. Co-administration of darexaban-MR did not impact the steady-state PK profile of digoxin.
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Affiliation(s)
- Takeshi Kadokura
- Astellas Pharma Inc, 3-17-1, Hasune, Itabashi-ku, Tokyo, 174-8612, Japan,
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