BACKGROUND: Pharmacologic thromboprophylaxis reduces the risk for venous thromboembolism after total hip replacement (THR) or total knee replacement (TKR). New oral anticoagulants (NOACs), including direct thrombin inhibitors and factor Xa inhibitors, are emerging options for thromboprophylaxis after these procedures.
PURPOSE: To compare the benefits and risks of NOACs versus standard thromboprophylaxis for adults having THR or TKR.
DATA SOURCES: MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from January 2009 through March 2013.
STUDY SELECTION: English-language systematic reviews.
DATA EXTRACTION: Two independent reviewers abstracted data and rated study quality and strength of evidence.
DATA SYNTHESIS: Six good-quality systematic reviews compared NOACs with low-molecular-weight heparin (LMWH) for thromboprophylaxis after THR or TKR. Risk for symptomatic deep venous thrombosis, but not risk for death or nonfatal pulmonary embolism, was reduced with factor Xa inhibitors compared with LMWH (4 fewer events per 1000 patients). Conversely, the risk for major bleeding increased (2 more events per 1000 patients). Outcomes of dabigatran did not significantly differ from those of LMWH. Indirect evaluation of NOACs by common comparison with LMWH showed nonsignificantly reduced risks for venous thromboembolism with rivaroxaban compared with dabigatran (risk ratio [RR], 0.68 [95% CI, 0.21 to 2.23]) and apixaban (RR, 0.59 [CI, 0.26 to 1.33]) but increased major bleeding. New oral anticoagulants have not been compared with warfarin, aspirin, or unfractionated heparin.
LIMITATIONS: Head-to-head comparisons among NOACs were not available. Efficacy is uncertain in routine clinical practice.
CONCLUSION: New oral anticoagulants are effective for thromboprophylaxis after THR and TKR. Their clinical benefits over LMWH are marginal and offset by increased risk for major bleeding.
PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs.
Norwegian Knowledge Centre for the Health Services has on request from Lovisenberg Diakonale Hospital reviewed the scientific evidence on the effect of graduated compression stockings (GCS) for prevention of deep vein thrombosis (DVT) among surgical and medical patients in hospitals.
Systematic literature search was carried out in relevant medical databases. We included tree systematic reviews. The systematic reviews had moderately to high methodological quality.
The evidence indicates that GCS prevents the formation of DVT among surgical patients, both alone and on a background of other prophylactic methods. It seems that knee length GCS is as effective in prevention of DVT as thigh length GCS. The evidence of GCS for prevention of DVT is less conclusive regarding medical patients.
Use of GCS also prevents development of post thrombotic syndrome, i.e. a condition that can occur after DVT.
Further research is necessary to identify which compression graduate is more effective and duration of time that GCS should be worn to prevent DVT.
Pharmacologic thromboprophylaxis reduces the risk for venous thromboembolism after total hip replacement (THR) or total knee replacement (TKR). New oral anticoagulants (NOACs), including direct thrombin inhibitors and factor Xa inhibitors, are emerging options for thromboprophylaxis after these procedures.
PURPOSE:
To compare the benefits and risks of NOACs versus standard thromboprophylaxis for adults having THR or TKR.
DATA SOURCES:
MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from January 2009 through March 2013.
STUDY SELECTION:
English-language systematic reviews.
DATA EXTRACTION:
Two independent reviewers abstracted data and rated study quality and strength of evidence.
DATA SYNTHESIS:
Six good-quality systematic reviews compared NOACs with low-molecular-weight heparin (LMWH) for thromboprophylaxis after THR or TKR. Risk for symptomatic deep venous thrombosis, but not risk for death or nonfatal pulmonary embolism, was reduced with factor Xa inhibitors compared with LMWH (4 fewer events per 1000 patients). Conversely, the risk for major bleeding increased (2 more events per 1000 patients). Outcomes of dabigatran did not significantly differ from those of LMWH. Indirect evaluation of NOACs by common comparison with LMWH showed nonsignificantly reduced risks for venous thromboembolism with rivaroxaban compared with dabigatran (risk ratio [RR], 0.68 [95% CI, 0.21 to 2.23]) and apixaban (RR, 0.59 [CI, 0.26 to 1.33]) but increased major bleeding. New oral anticoagulants have not been compared with warfarin, aspirin, or unfractionated heparin.
LIMITATIONS:
Head-to-head comparisons among NOACs were not available. Efficacy is uncertain in routine clinical practice.
CONCLUSION:
New oral anticoagulants are effective for thromboprophylaxis after THR and TKR. Their clinical benefits over LMWH are marginal and offset by increased risk for major bleeding.
