Safety of fondaparinux versus enoxaparin after TKA in Japanese patients

Efficacy of 11 anticoagulants for the prevention of venous thromboembolism after total hip or knee arthroplasty: A systematic review and network meta-analysis

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.

Does intraoperative mechanical prophylaxis prevent venous thromboembolism in total knee arthroplasty? - effectiveness of passive-assisted ankle motion in surgical/non-surgical side

BACKGROUND

Gradual compression stocking (GCS) and intermittent pneumatic compression device (IPCD) are used for intraoperative mechanical prophylaxis against venous thromboembolism (VTE) during total knee arthroplasty (TKA). In this study, we applied a passive-assisted ankle motion in combination with GCS and IPCD during TKA and evaluated its effectiveness in preventing postoperative VTE.

METHODS

We included 77 patients who underwent primary unilateral TKA. Patients were divided into group A (53 patients who underwent GCS and IPCD on their non-surgical side limb) and group B (24 patients who underwent passive ankle dorsiflexion motion in addition to GCS and IPCD on their non-surgical side limb). Deep vein thrombosis (DVT) was assessed using lower extremity ultrasonography (US). The incidence of VTE in each affected limb was compared between the two groups.

RESULTS

US was performed 4 days after surgery on average. The incidence of DVT in groups A and B was 47.2 and 70.8 %, respectively. In group A, 22.6 % of DVTs were found only on the surgical side, 11.3 % on the non-surgical side, and 13.2 % on both sides. On the other hand, in group B, 41.7 % of DVTs were found only on the surgical side, 4.2 % on the non-surgical side, and 25.0 % on both sides. No significant difference in the incidence of VTE was noted between the 2 groups.

CONCLUSIONS

The intraoperative application of passive ankle motion plus GCS and IPCD might not further reduce the incidence of postoperative DVT in TKA patients.

Efficacy and safety of anticoagulants for postoperative thrombophylaxis in total hip and knee arthroplasty: A PRISMA-compliant Bayesian network meta-analysis

Objective

To search, review, and analyze the efficacy and safety of various anticoagulants from randomized clinical trials (RCTs) of anticoagulants for THA and TKA.

Design

PRISMA-compliant Bayesian Network Meta-analysis.

Data sources and study selection

The databases of The Medline, Embase, ClinicalTrial, and Cochrane Library databases were searched until March 2017 for RCTs of patients undergoing a THA or TKA.

Main outcomes and measures

The primary efficacy measurement was the venous thromboembolism Odds ratio (OR). The safety measurement was the odds ratio of major or clinically relevant bleeding. OR with 95% credibility intervals (95%CrIs) were calculated. Findings were interpreted as associations when the 95%CrIs excluded the null value.

Results

Thirty-five RCTs (53787 patients; mean age range, mostly 55–70 years; mean weight range, mostly 55–90 kg; and a higher mean proportion of women than men, around 60%) included the following Anticoagulants categories: fondaparinux, edoxaban, rivaroxaban, apixaban, dabigatran, low-molecular-weight heparin, ximelagatran, aspirin, warfarin. Anticoagulants were ranked for effectiveness as follows: fondaparinux (88.89% ± 10.90%), edoxaban (85.87% ± 13.34%), rivaroxaban (86.08% ± 10.23%), apixaban (68.26% ± 10.82%), dabigatran (41.63% ± 12.26%), low-molecular-weight heparin (41.03% ± 9.60%), ximelagatran (37.81% ± 15.87%), aspirin (35.62% ± 20.60%), warfarin (9.89% ± 9.07%), and placebo (4.56% ± 6.37%). Ranking based on clinically relevant bleeding events was as follows: fondaparinux (14.53% ± 15.25%), ximelagatran (18.93% ± 17.49%), rivaroxaban (23.86% ± 15.14%), dabigatran (28.30% ± 14.18%), edoxaban (38.76% ± 24.25%), low-molecular-weight heparin (53.28% ± 8.40%), apixaban (71.81% ± 10.92%), placebo (76.26% ± 14.61%), aspirin (86.32% ± 25.74%), and warfarin (87.95% ± 11.27%). No statistically significant heterogeneity was observed between trials.

Conclusions and relevance

According to our results, all anticoagulant drugs showed some effectiveness for VTE prophylaxis. Our ranking indicated that fondaparinux and rivaroxaban were safer and more effective than other anticoagulant drugs for patients undergoing THA or TKA.

Comparison of the Effects of Low-Molecular-Weight Heparin and Fondaparinux on Liver Function in Patients With Pulmonary Embolism

Hepatotoxicity with low-molecular-weight heparin (LMWH) or fondaparinux is a relatively common adverse reaction. This study assessed the effects of LMWH and fondaparinux on liver function in patients with pulmonary embolism based on a retrospective cohort. As a result, a total of 463 patients with pulmonary embolism and treated with LMWH (enoxaparin sodium or nadroparin calcium) or fondaparinux sodium were included. Liver dysfunction was identified in 79 patients (17.1%), of whom 97.5% had grade 1 drug-induced liver injury (DILI) and 2.5% had grade 2 DILI. The results showed that liver dysfunction usually occurred in the first week after anticoagulant administration, and the liver tests of all patients with liver dysfunction gradually recovered or alleviated at discharge. The multivariable logistic regression analysis indicated that a longer treatment course and hepatitis B surface antigen-positive (HBsAg+) were risk factors for liver dysfunction (P < .05). Moreover, nadroparin calcium had the highest risk of liver dysfunction, approximately 2.2 times (95% confidence interval [CI], 1.1740-4.224; P = .015) that of enoxaparin sodium. In conclusion, nearly one-fifth and 10% of patients prescribed with LMWH or fondaparinux, respectively, for pulmonary embolism had liver dysfunction, mainly with mild liver injury and characterized by self-limited elevated serum transaminase levels. Hence, during the 3 anticoagulant applications, we should pay more attention to the monitoring of liver function in the first week and transit to oral anticoagulants if possible, especially for patients who are HBsAg+ or suffering from other liver diseases.

Comparison of pharmacologic prophylaxis in prevention of venous thromboembolism following total knee arthroplasty

BACKGROUND

Anticoagulants are used following total knee arthroplasty (TKA) to prevent venous thromboembolism (VTE). These drugs reduce VTE risk but may lead to bleeding-related complications. Recently, surgeons have advocated using antiplatelet agents including aspirin (ASA). However, there is no consensus regarding which medication has the optimal risk/benefit profile. The purpose of this study was to compare rates of VTE using different anticoagulants in anticoagulation-naïve patients being discharged home after TKA.

METHODS

A national private insurance database was used to identify patients undergoing unilateral TKA. Patients with a prior history of VTE were excluded. Anticoagulants included ASA, low molecular weight heparin (LMWH), warfarin, factor Xa inhibitors (XaI), and fondaparinux. Postoperative complications, including VTE, blood transfusion, myocardial infarction, and hematoma, were identified using ICD-9 diagnosis codes. Risk of each complication was compared between groups using multivariate logistic regression controlling for demographics, length of stay, and comorbidities.

RESULTS

Of 30,813 patients, 1.82% were diagnosed with VTE. Using ASA as a baseline, there was significantly decreased risk of VTE with LMWH (OR 0.47), XaI (OR 0.50), and fondaparinux (OR 0.32). There was significantly higher risk of transfusion with LMWH (OR 1.56) and fondaparinux (OR 1.84), but no difference in hematoma between medications.

CONCLUSIONS

This study shows that there is a decreased risk of VTE with LMWH, XaI, and fondaparinux compared to ASA. However, these medications also had higher rates of bleeding-associated complications. The choice of pharmacologic prophylaxis should be made based on a balance of the risk/benefit profile of each medication.

LEVEL OF EVIDENCE

III.

Efficacy and safety of venous thromboembolism prophylaxis with fondaparinux in women at risk after cesarean section

Objectives

Cesarean section is associated with an increased risk for venous thromboembolism (VTE). The safety and efficacy of primary prophylaxis of fondaparinux, a synthetic sulfated pentasaccharide heparin analog, in women at risk after cesarean section is uncertain.

Methods

This was a retrospective study of 295 cases of pregnant women presenting to a tertiary referral center of Nara, Japan, to evaluate the usefulness of thromboprophylaxis with fondaparinux after cesarean delivery between 2011 and 2012. Patients were initially received unfractionated heparin (once 5,000 IU subcutaneously, twice a day), starting 6 hours after cesarean section for 24 hours, and then treated with fondaparinux (once 2.5 mg daily, subcutaneously) for 5 days. The primary efficacy end-point was an improvement in the incidence of symptomatic VTE or fatal post-cesarean pulmonary thromboembolism. The primary safety end-point was major bleeding during treatment.

Results

There were neither any episodes of symptomatic VTE cases nor maternal deaths. A total of 10 patients had a bleeding event. Major bleeding complication was observed in 2 (0.68%) of 295 patients receiving fondaparinux. Non-major bleeding into critical sites was observed in 8 patients, often at surgical sites, and recovery was not delayed.

Conclusion

This study demonstrates the safety and efficacy of fondaparinux in women at high risk of VTE after cesarean section. Large phase trials comparing clinical outcomes with fondaparinux across a wide spectrum of patients are needed to confirm these observations.

Closed Suction Drainage Is Not Associated with Faster Recovery after Total Knee Arthroplasty: A Prospective Randomized Controlled Study of 80 Patients

OBJECTIVE

To evaluate whether closed suction drainage (CSD) is associated with early recovery of knee function in patients undergoing total knee arthroplasty (TKA).

METHODS

Between January 2015 and September 2015, 80 consecutive patients were prospectively randomized into two groups: a CSD group (40 cases; average age, 66.9 ± 8.6 years; male, 8; female, 32) and a non-CSD group (40 cases; average age, 66.8 ± 10.1 years; male, 9; female, 31). Local inflammation outcomes (assessed by a visual analog scale [VAS], swelling and skin temperature), calculated total blood loss (CBL), hidden blood loss (HBL), blood transfusion requirements and hemoglobin concentrations were recorded. Hospital for Special Surgery (HSS) knee scores, range of motion (ROM), limb swelling, tension vesicles, ecchymosis, time to regaining straight leg raising and duration of hospital stay were documented. All surgeries were performed by the same surgeon and followed up for 3 months.

RESULTS

The peri-wound skin temperature and knee VAS pain scores were lower in the non-CSD group. Patients in the non-CSD group had significantly better knee ROM (P = 0.028). The time to regaining active straight leg raising was significantly shorter in the non-CSD groupN than in the CSD group (P = 0.014). In addition, patients in the non-CSD group had a shorter length of hospital stay (P = 0.004) than those in the CSD group, indicating earlier recovery of knee function. HBL was significantly less in the CSD group than the non-CSD group (P = 0.006) on postoperative day (POD) 5. However, CBL did not differ significantly between the two groups on POD5. There were no significant differences between two groups in all other assessed variables.

CONCLUSION

In this randomized study, primary TKA without CSD was associated with faster recovery related to less local inflammation and better early knee function. Furthermore, use of a drain had no significant advantage with respect to other outcome measures and may have increased costs. Based on these data, CSD after primary TKA is not routinely indicated.

Is closed suction drainage effective in early recovery of hip joint function? Comparative evaluation in one-stage bilateral total hip arthroplasty

One-stage primary bilateral cementless total hip arthroplasty with unilateral closed suction drainage (CSD) was prospectively performed for 51 patients (102 hips), and local effects of CSD were quantitatively evaluated. Postoperatively, pain scores evaluated by visual analog scale and periwound temperatures measured by thermography were lower in the CSD side than the non-CSD side. CT measurements also showed that postoperative cross-sectional area of the thigh was smaller in the CSD side. Active straight leg raising and weight bearing were more accelerated in the CSD side., showing earlier recovery of hip joint function. CSD for hip arthroplasty has an advantage in reducing postoperative local inflammation and be recommended from the viewpoint of postoperative pain relief and early recovery of hip joint function.