Direct oral Xa inhibitors demonstrate a favorable profile for preventing venous thromboembolism (VTE) compared with low-molecular-weight heparin (LMWH) after total hip and knee replacement. This conclusion stems from a comprehensive analysis of various VTE prophylaxis options.
Comparing VTE Prophylaxis Options: A Comprehensive Analysis
Numerous trials and meta-analyses compare VTE prophylaxis options after total hip and knee replacement (THR and TKR). However, a simultaneous comparison of newer and older options was lacking. This analysis aimed to address this gap by evaluating the relative risk of VTE and hemorrhage for twelve different prophylaxis options.
Methodology: Building a Network of Comparisons
Data on VTE and hemorrhage were extracted from randomized controlled trials published between January 1990 and June 2016, comparing twelve prophylaxis options. A network meta-analysis was constructed to compute the relative risk for each option compared to once-daily low-dose LMWH (LMWH Low).
Results: Direct Oral Xa Inhibitors Show Favorable Profile
Compared to LMWH Low, direct oral Xa inhibitors demonstrated the lowest risk of total deep vein thrombosis (DVT), both asymptomatic and symptomatic (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.35-0.57). This translates to a reduction of 53-139 DVT events per 1000 patients.
Vitamin K antagonists (VKAs) titrated to an International Normalized Ratio (INR) of 2-3 predicted a 56% increase in DVT events (OR, 1.56; 95% CI, 1.14-2.14). Aspirin showed similar performance to LMWH Low (OR, 0.80; 95% CI, 0.34-1.86), though limited data prevent definitive conclusions. Importantly, direct oral Xa inhibitors did not significantly increase bleeding risk (OR, 1.21; 95% CI, 0.79-1.90).
Furthermore, direct oral Xa inhibitors prevented four times more symptomatic DVTs compared to LMWH Low (OR, 0.25; 95% CI, 0.13-0.47).
Conclusion: Implications for Clinical Practice
This comparative analysis reveals that direct oral Xa inhibitors offer a more favorable profile regarding VTE and hemorrhage risk compared to LMWH Low, while VKAs present a less favorable profile. Other agents did not demonstrate a significantly different profile compared to LMWH Low. Clinicians should consider these findings when choosing the most appropriate VTE prophylaxis option for their patients undergoing THR and TKR.
