Venous thromboprophylaxis after total hip arthroplasty: aspirin, warfarin, enoxaparin, or factor Xa inhibitors?

Abstract

Introduction: Debate over the ideal agent for venous thromboembolism (VTE) prophylaxis after total hip arthroplasty (THA) has led to changes in prescribing trends of commonly used agents. We investigate variation in utilisation and the differences in VTE incidence and bleeding risk in primary THA after administration of aspirin, warfarin, enoxaparin, or factor Xa inhibitors. Methods: 8829 patients were age/sex matched from a large database of primary THAs performed between 2007 and 2016. Utilisation was calculated using compound annual growth rate. Incidence of postoperative deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding-related complications, postoperative anaemia, and transfusion were identified at 2 weeks, 30 days, 6 weeks, and 90 days. Results: Aspirin use increased by 33%, enoxaparin by 7%, and factor Xa inhibitors by 31%. Warfarin use decreased by 1%. Factor Xa inhibitors (1.7%) and aspirin (1.7%) had the lowest incidence of DVT followed by enoxaparin (2.6%), and warfarin (3.7%) at 90 days. Factor Xa inhibitors (12%) and aspirin (12%) had the lowest incidence of blood transfusion followed by warfarin (15%) and enoxaparin (17%) at 90 days. There was no difference in incidence of blood transfusion or bleeding-related complications nor any detectable difference in symptomatic PE incidence. Conclusions: The utilisation of aspirin and factor Xa inhibitors increased over time. Aspirin and factor Xa inhibitors provided improved DVT prophylaxis with lower rates of postoperative anaemia compared to enoxaparin and warfarin.

History of COVID-19 infection is not associated with increased d-dimer levels and risk of deep-vein thrombosis in total joint arthroplasty

“…Parvizi et al analyzed 4651 primary total joint arthroplasty cases and found a symptomatic DVT rate of 0.1% when using 81 mg ASA and of 0.3% when using 325 mg ASA [ 24 ]. In a study by Bala et al, Factor Xa inhibitors (1.7%) and aspirin (1.7%) had the lowest incidence of symptomatic DVT at 90 days, followed by enoxaparin (2.6%), and warfarin (3.7%) [ 3 ]. The later study showed a higher rate of symptomatic postoperative DVT compared to the current group of SARS-CoV-2 IgG-positive patients.…”

Aspirin as venous thromboembolism prophylaxis in total joint arthroplasty: a narrative review of the current evidence

“…While enoxaparin, warfarin, rivaroxaban, and apixaban demonstrated odds ratio for I&D of 0.55, 2.04, 0.55, and 0.25, respectively. Bala et al 16 evaluated the use of ASA in the patients after THAs, as they did in the patients after TKAs. Their data demonstrated similar efficacy and safety in the ASA patients as compared with the patients who received other forms chemoprophylaxis.…”

“…Their data demonstrated similar efficacy and safety in the ASA patients as compared with the patients who received other forms chemoprophylaxis. 16 An et al 10 reported data specific to the patients after THAs in their study. They used the same protocol in THAs as they did in TKAs: ASA 300 mg daily for 5 days, transitioning to ASA 100 mg daily for 5 wk in the outpatient setting.…”

“…In aggregate, the rate of symptomatic VTE in the studies selected for this review ranged from 0.16% to 1.7% with ASA as chemoprophylaxis in the patients after THAs. 8,10,12,[16][17][18] Faour et al 18 did further analysis in the 7,488 patients who underwent THAs. The patients received either low-dose ASA (81 mg twice daily), or high-dose ASA (325 mg twice daily) for 4 to 6 wk.…”

“…Lastly, surgical-site bleeding that requires additional surgery is a major bleeding event. 11,16,17,36 ASA generally has been reported to have less bleeding risk than other chemoprophylaxis agents. However, inherent to ASA is its risk in causing gastrointestinal ulceration and bleeding.…”