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Comparative effectiveness of venous thromboembolism prophylaxis options for the patient undergoing total hip and knee replacement: a network meta‐analysis
Author(s) -
Kapoor A.,
Ellis A.,
Shaffer N.,
Gurwitz J.,
Chandramohan A.,
Saulino J.,
Ishak A.,
Okubanjo T.,
Michota F.,
Hylek E.,
Trikalinos T. A
Publication year - 2017
Publication title -
journal of thrombosis and haemostasis
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.947
H-Index - 178
eISSN - 1538-7836
pISSN - 1538-7933
DOI - 10.1111/jth.13566
Subject(s) - medicine , relative risk , odds ratio , confidence interval , low molecular weight heparin , deep vein , knee replacement , fondaparinux , meta analysis , randomized controlled trial , venous thrombosis , vitamin k antagonist , aspirin , thrombosis , number needed to treat , venous thromboembolism , surgery , arthroplasty , warfarin , atrial fibrillation
Essentials Despite trial data, guidelines have not endorsed direct oral Xa inhibitors above other options. We provide profiles of venous thromboembolism and hemorrhage risk for 12 options. Direct oral Xa inhibitors had a favorable profile compared with low‐molecular‐weight heparin. Other options did not have favorable profiles compared with low‐molecular‐weight heparin.Summary Background There are numerous trials and several meta‐analyses comparing venous thromboembolism ( VTE ) prophylaxis options after total hip and knee replacement ( THR and TKR ). None have included simultaneous comparison of new with older options. Objective To measure simultaneously the relative risk of VTE and hemorrhage for 12 prophylaxis options. Methods We abstracted VTE and hemorrhage information from randomized controlled trials published between January 1990 and June 2016 comparing 12 prophylaxis options. We then constructed networks to compute the relative risk for each option, relative to once‐daily dosing with low‐molecular‐weight heparin ( LMWH ) Low. Results Main : Relative to LMWH Low, direct oral Xa inhibitors had the lowest risk of total deep vein thrombosis ( DVT )‐asymptomatic and symptomatic‐ (odds ratio [ OR ], 0.45; 95% confidence interval [ CI ], 0.35–0.57), translating to 53–139 fewer DVT s per 1000 patients. Vitamin K antagonists ( VKA s) titrated to International Normalized Ratio [ INR ] 2–3 predicted 56% more DVT events ( OR , 1.56; 95% CI , 1.14–2.14). Aspirin performed similarly ( OR , 0.80; 95% CI , 0.34–1.86), although small numbers prohibit firm conclusions. Direct oral Xa inhibitors did not lead to significantly more bleeding ( OR , 1.21; 95% CI , 0.79‐1.90). Secondary : Relative to LMWH Low, direct oral Xa inhibitors prevented 4‐fold more symptomatic DVT s ( OR , 0.25; 95% CI , 0.13–0.47). Conclusions Relative to LMWH Low, direct oral Xa inhibitors had a more favorable profile of VTE and hemorrhage risk, whereas VKA s had a less favorable profile. The profile of other agents was not more or less favorable. Clinicians should consider these profiles when selecting prophylaxis options.