New Oral Anticoagulants for Venous Thromboembolism Prophylaxis in Total Hip and Knee Arthroplasty: A Systematic Review and Network Meta-Analysis

Abstract

Background: There is controversy over whether use of new oral anticoagulants (NOACs) associates with increased hemorrhage risk compared with non-NOAC. Meanwhile, determining which NOAC to use remains unclear. We aimed to summarize the evidence about NOACs in venous thromboembolism (VTE) prevention for patients with total hip and knee arthroplasty (THA and TKA).Methods: We searched RCTs assessing NOACs for VTE prophylaxis in adults undergoing THA and TKA in Medline, Embase, and Cochrane up to May 2021. Primary outcomes were VTE [included deep vein thrombosis (DVT) and pulmonary embolism (PE)], major VTE, and major bleeding. The rank probabilities of each treatment were summarized by the surface under the cumulative ranking curve area (SUCRA).Results: 25 RCTs with 42,994 patients were included. Compared with non-NOAC, NOACs were associated with a decreased risk of VTE (RR 0.68; 95% CI 0.55–0.84) and major VTE (RR = 0.52; 95% CI 0.35–0.76). Additionally, rivaroxaban, apixaban, and edoxaban but not dabigatran and betrixaban, did confer a higher efficacy compared with non-NOAC. None of the individual NOACs increased the risk of bleeding, while apixaban and betrixaban were even associated with a decreased risk of bleeding. In the comparison of different NOACs, rivaroxaban was associated with the greatest benefits in VTE (SUCRA = 79.6), DVT (SUCRA = 88.8), and major VTE (SUCRA = 89.9) prevention. Furthermore, subgroup analysis confirmed that NOACs associated with a higher efficacy tendency in patients with follow-up duration <60 days than follow-up duration ≥60 days.Conclusion: Evidence suggests that NOACs exert more benefits on VTE prophylaxis, and none of the individual NOACs increased hemorrhage compared with non-NOAC. Among various NOACs, rivaroxaban is recommended in patients with lower bleeding risk, and apixaban is recommended in patients with higher bleeding risk.Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021266890].

Population Pharmacokinetics and Hemorrhagic Risk Analysis of Rivaroxaban in Elderly Chinese Patients With Nonvalvular Atrial Fibrillation

“…Hemorrhage events mostly occurred with anticoagulation therapy. In previous studies, approximately 17.24% of patients experienced bleeding events after treatment with rivaroxaban 14 . In elderly patients, certain comorbidities (renal insufficiency in particular) were more commonly affected by rivaroxaban pharmacokinetics and pharmacodynamics.…”

“…In previous studies, approximately 17.24% of patients experienced bleeding events after treatment with rivaroxaban. 14 In elderly patients, certain comorbidities (renal insufficiency in particular) were more commonly affected by rivaroxaban pharmacokinetics and pharmacodynamics. Recent studies conducted in Korea and Japan demonstrated that lowdose rivaroxaban was associated with a lower risk of hemorrhage and all-cause mortality in the management of patients with nonvalvular atrial fibrillation.…”

Awareness and Perception of Hospitalized Patients on Thromboembolism and Thromboprophylaxis: A Cross-Sectional Study in Sana’a-Yemen

“…Evidence shows that NOACs exert more clinical benefits without increase in hemorrhage in Total Hip and Knee Arthroplasty compared with traditional non-NOACs. 7 Mechanical prophylaxis (eg, antiembolism stockings or intermittent pneumatic compression) can be provided to the hospitalized patients in whom pharmacological prophylaxis is contraindicated, and they as well should be extended until the patient is adequately able to walk. 8 Evidence supports that all hospitalized patients should be counselled about the risk factors and consequences of VTE, the adverse effects of thromboprophylaxis medications, and the appropriate risk-reduction modalities prior to initiating thromboprophylaxis.…”

Pharmacotherapy for Venous Thromboprophylaxis following Total Hip or Knee Arthroplasty: A Systematic Review and Network Meta-analysis

“…20 Prior systematic reviews and meta-analyses have investigated pharmacological thromboprophylaxis in smaller patient populations or intervention groups with unspecified treatment details. While other analyses have found that rivaroxaban was associated with the greatest reduction in deep vein thrombosis (DVT), they were limited by the patient population (only TKAs 27 ), or by interventions (comparisons between NOACs and non-NOACs unclear 28 ; exclusion of important interventions including aspirin, apixaban, edoxaban 29 ). These analyses included a small number of randomized controlled trials (RCTs) 30,31 and included studies which report on doses or regimens of medications which fall outside of current treatment guidelines, which limits the applicability of their results.…”