Page 5 - OrthoFeed-Jun'21

Prophylaxis Pharmacotherapy

Thromboprophylaxis for total knee replacement Opioid-prescribing practices after common

or total hip replacement surgery orthopaedic procedures

Dr. Milind Patil 12 12 10 Dr Vivek Mittal Target areas for future initiatives
10
Incidence of DVT A quality improvement questionnaire study was
Joint Replacement Surgeon 8 6 Orthopedic Surgeon

Revival Bone and Joint Hospital, Thane 4 2 2 BLK Super Speciality Hospital, New Delhi conducted among orthopedic surgeons to assess the
0
potential opioid safety initiatives.
No prophylaxis LMWH Rivaroxaban prescribing practices and gain perspective on
[1]
Introduction Introduction
Fig: Incidence of DVT per 1000 patients after no prophylaxis and
thromboprophylaxis with LMWH and Rivaroxaban [3] The opioid prescribing practices can be improved by
Acute and chronic pain carries grave economic, developing training programs, increasing awareness,
Venous thromboembolism (VTE) is a serious Total mortality also reduced from 5 to 2 per 1,000 with operational, and personal consequences. [1]
complication of orthopedic surgery. [1] rivaroxaban as compared to LMWH. [3] use of opioid tracking databases, and formulation of a
standardized recommended dose for common
Despite the guidelines promoting conservative pain [1]
Low molecular weight heparin (LMWH) has been the Conclusion management, narcotic prescriptions have increased orthopedic surgeries.
standard of care for thromboprophylaxis after total by 51% and fatal opioid overdoses tripled over the last
knee replacement (TKR) or total hip replacement 6 years. [1] Clinical implication
(THR) surgery. [1] For patients undergoing THA/TKA, the evidence is
strong and sufficient to conclude that
thromboprophylaxis with rivaroxaban is associated But, opioids are the mainstay of pain management The knowledge of opioid prescription variability and
However, direct oral anticoagulants (DOACs) are following orthopedic surgery. [1] the prevailing opioid epidemic needs to be addressed
increasingly being used as alternatives. [1] with better efficacy outcomes when compared with and resolved in the Indian scenario.
LMWH, without significant differences in major
bleeding and overall mortality. Therefore, to balance the benefits with the involved
International guidelines for risks the opioids should be judiciously prescribed. [1] This review can serve as an exemplar for the
thromboprophylaxis References reevaluation of recommendations and institutional
practices to reduce excess postoperative opioid
The most recent National Institute for health & Care 1.Haykal T, Adam S, Bala A, et al. Thromboprophylaxis for Variability in Opioid-prescribing Practic- prescriptions.
Excellence (NICE 2018) guidelines recommend orthopedic surgery; An updated meta-analysis. Thromb Res. es [2]
anticoagulation with rivaroxaban or LMWH after 2021;199:43-53.
total hip or knee arthroplasty. [2] 2.D.R. Anderson, G.P. Morgano, C. Bennett, F. Dentali, C.W. Level III observational cohort study evaluated the References
Francis, D.A. Garcia, et al., American Society of Hematology 2019 trends and variability in opioid prescriptions after
Both ACCP (2012) and American Society of guidelines for management of venous thromboembolism: 1.Kopp, J. A., Anderson, A. B. et al. (2019). Orthopedic Surgeon
Hematology (ASH 2019) recommends extended prevention of venous thromboembolism in surgical hospitalized common orthopedic procedures. Decision-Making Processes for Postsurgical Opioid Prescribing.
prophylaxis of 35 days and 19-42 days respectively patients, Blood Adv 3 (23) (2019) 3898–3944. Military Medicine. Military Medicine, Vol. 185, March/April 2020
over short-term prophylaxis. [2, 3] A retrospective study from 2015 and 2016
3.Y. Falck-Ytter, C.W. Francis, N.A. Johanson, C. Curley, O.E. Dahl,
2.Traven, Sophia A. MD; Brinton, Daniel L. PhD; Woolf, Shane K.
S. Schulman, et al., Prevention of VTE in orthopedic surgery Data on 73,921 subjects who underwent common
Extended thromboprophylaxis with orthopaedic procedures MD; Leddy, Lee R. MD; Gottschalk, Michael B. MD; Slone, Harris S.
patients: antithrombotic therapy and prevention of thrombosis,
Rivaroxaban 9th ed: American College of Chest Physicians Evidence- Based From Truven Health Market Scan database MD Notable Variability in Opioid-prescribing Practices After
Common Orthopaedic Procedures, Journal of the American
Clinical Practice Guidelines, Chest 141 (2 Suppl) (2012)
The RECORD clinical trial program has earlier e278S–e325S. Academy of Orthopaedic Surgeons: March 1, 2021 - Volume 29 -
established the better efficacy of rivaroxaban over Initial opioid 90-day prescription Issue 5 - p 219-226.
(initial + refills)
prescription
LMWH in VTE prevention post TKA/THA [4] 4.Russell RD, Hotchkiss WR, Knight JR, Huo MH. The efficacy and
safety of rivaroxaban for venous thromboembolism prophylaxis
after total hip and total knee arthroplasty. Thrombosis.
In addition, the extended use of rivaroxaban was
studied in a prospective trial enrolling 2,400 patients 2013;2013:762310. doi:10.1155/2013/762310 Median oral morphine equivalent and
Interquartile range were analyzed
after THA. [3]
Eight fewer symptomatic DVT per 1,000 was achieved Patients undergoing soft-tissue only precedures required
with rivaroxaban over LMWH after 34-day the fewest refills while patients undergoing
prophylaxis. [3] total joint arthroplasty required the most.

[Ref: 2]