A retrospective analysis of bleeding risk with rivaroxaban, enoxaparin, and aspirin following total joint arthroplasty or revision

Abstract

Study Objective: Rivaroxaban, enoxaparin, and aspirin are commonly used medications for thromboprophylaxis following lower extremity joint arthroplasty or revision.Previous research has demonstrated efficacy in preventing venous thromboembolism with each medication, however, the comparative risk of bleeding between them remains poorly understood. The aim of this study was to compare the odds of bleeding between rivaroxaban, enoxaparin, and aspirin following lower extremity joint arthroplasty or revision.Design: This is a 3-year retrospective cohort study. Setting: Data were obtained from 148 facilities across 55 states and territories of the United States. Patients: This study included 85,938 patients who underwent hip or knee arthroplasty or revision. Intervention: Patients received enoxaparin, rivaroxaban, or aspirin as monotherapy for thromboprophylaxis. Measurements: The primary outcome was all bleeding, classified as major or minor bleeding, occurring in the 40 days following surgery. The secondary outcome was venous thromboembolism.Main Results: Among 85,938 patients, 10,465 received rivaroxaban, 14,047 received enoxaparin, and 61,426 received aspirin. Bleeding occurred in 126 (1.20%) patients with rivaroxaban, 253 (1.80%) with enoxaparin, and 611 (0.99%) with aspirin. There was a significant increase in odds of bleeding in the enoxaparin compared to aspirin group odds ratio (OR) 1.18, 95% confidence interval (CI) 1.01-1.38, p = 0.042), and a trend toward increased odds of bleeding in rivaroxaban compared to aspirin group (OR 1.21, 95% CI 0.99-1.47, p = 0.058) and rivaroxaban compared to enoxaparin (OR 1.03, 95% CI 0.82-1.28, p = 0.827). Odds of venous thromboembolism were not statistically significant between all three study medications.Conclusions: Among rivaroxaban, enoxaparin, and aspirin used for thromboprophylaxis in knee and hip arthroplasty or revision, aspirin had significantly decreased odds of bleeding complications compared to enoxaparin. Although not statistically | 609 WATTS eT Al.

Recommendations from the ICM-VTE: General

“…The majority received ASA (n = 61,426), demonstrating a significant shift in practice. ASA had a lower rate of wound complications compared to enoxaparin and rivaroxaban, although the latter comparison did not reach statistical significance 2102 .…”

“…Aspirin (ASA): ASA may reduce the incidence of wound complications and PJI when compared to warfarin, Factor Xa inhibitors, LMWH and direct thrombin inhibitors, as mentioned in the above sections 2085,2096,2102,2103,2107 . ASA has also demonstrated efficacy in patients at high-risk of VTE 2083 .…”

“…The risk may be further increased when potent anticoagulants drugs are administered in comparison to ASA [2040][2041][2042] , but some authors report conflicting results 2043 , and the rates may be different for THA and TKA 2025 . There is little evidence that different potent anticoagulants agents other than ASA are associated with different risks of bleeding 2044,2045 .…”

Aspirin and the Hip: Back to the Future? A 70-Year History

“…For the orthopaedic surgeon, the question remains simple: is it possible to predict and prevent a pulmonary embolism, particularly a fatal one? The prevalence of a fatal pulmonary embolism after hip arthroplasty is around 1.8% without prophylaxis and around 0.1% with any method of prevention 4 . Surgeons must remember that predicting the future remains difficult (even impossible).…”

“…Many drugs were tested and approved by regulatory agencies for the prevention of VTE. Yet, despite the millions of dollars spent on pharmaceutical research to develop new anticoagulants, we cannot answer 4 this simple question: Which is the best one? Ludwick et al confirm that aspirin, a drug known for 4,000 years, is still an actual pharmacologic approach for VTE prevention.…”