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Direct comparison of the DOACs for thromboprophylaxis after THA and TKA 11

Thromboprophylaxis Wound problem

Direct comparison of the DOACs for thromboprophylaxis after THA and TKA There was no significant difference between
the three DOACs with regards to wound
Endorsed by: Dr. Mahesh Kulkarni, Orthopedic Surgeon, Pune
problems resulting in discontinuation of the
Introduction study drug (0.4%, 0.7%, and 0.1% for

In 2007, 2009, and 2010 National Institute for Health & Care Excellence (NICE) published guidelines rivaroxaban, dabigatran, and apixaban,
recommended extended-duration chemical thromboprophylaxis for all patients undergoing respectively). 2

lower-limb arthroplasty. 1

Direct oral anticoagulants (DOACs) have promised superior efficacy over low molecular weight
heparins in the prevention of venous thromboembolism (VTE) in total hip arthroplasty (THA) and total

knee arthroplasty (TKA). 2

However, there are concerns raised about associated wound problems with these agents. 1

Need for clinical assessment Head to head comparison

Current clinical evidence is unclear about A prospective cohort study evaluated the
which prophylactic strategy (or strategies) comparative efficacy and safety of the three

is/are optimal or suboptimal for the prevention DOACs: rivaroxaban, dabigatran, and apixaban,
of venous thromboembolic disease in patients in a total of 2431 THA or TKA patients. 2

undergoing elective hip and knee arthroplasty. 3
Efficacy
2020;35(11):3093-3098.
Prolonged wound drainage after lower-limb Rivaroxaban had a statistically significant Conclusion
arthroplasty is associated with infection, superior efficacy for overall VTE (Venous Rivaroxaban appears to have superior efficacy in 3) Jacobs JJ, Mont MA, Bozic KJ, et al. American
Academy of Orthopaedic Surgeons clinical practice
longer hospital stay, re-operation, and thromboembolism) prevention (0.8% vs VTE prevention over apixaban and dabigatran, guideline on: preventing venous thromboembolic disease
in patients undergoing elective hip and knee arthroplasty. J
subsequent increase in the economic burden 2.6%) compared with dabigatran (P < 0.01) whilst no significant difference is observed in Bone Joint Surg Am. 2012;94(8):746-747.

on national resources. 1 and apixaban (P < 0.01). 2 wound problems with either rivaroxaban,

dabigatran or apixaban. 2
Most importantly, there is a dearth of direct DVT (deep vein thrombosis) prevention was
comparative study between the three DOACs also superior with rivaroxaban compared to References

for antithrombotic efficacy and occurrence of dabigatran (0.3% vs 2.2%) and apixaban
wound problem. 2 (0.3% vs 0.8%) (Table 1). 2 1) Jensen CD, Steval A, Partington PF, Reed MR, Muller SD.
Return to theatre following total hip and knee replacement,
before and after the introduction of rivaroxaban: a
retrospective cohort study. J Bone Joint Surg Br
In this scenario, AAOS’ (American Academy of Symptomatic PE (Pulmonary embolism) 2011;93:91e5.
Orthopaedic Surgeons) clinical practice was low across all study groups, with an
2) Highcock AJ, As-Sultany M, Finley R, Donnachie NJ. A
guidelines are also unable to recommend for overall rate of 0.8% (0.5%, 0.8%, and 1.3% in Prospective Cohort Comparative Study of Rivaroxaban,
Dabigatran, and Apixaban Oral Thromboprophylaxis in
or against specific prophylactics in these the rivaroxaban, dabigatran, and apixaban 2431 Hip and Knee Arthroplasty Patients: Primary Efficacy
patients. 3 groups, respectively). 2 Outcomes and Safety Profile. J Arthroplasty.