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Semin Thromb Hemost
DOI: 10.1055/s-0044-1787996
Review Article

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

Bryan Song Jun Yong‡   *
1   Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
,
Ryan Ruiyang Ling‡   *
2   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
,
Ruiqi Li
1   Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
,
Jane Wenjin Poh
1   Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
,
Chuen Seng Tan
3   Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
,
Sean Wei Loong Ho
1   Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
2   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
4   Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
,
Bram Rochwerg
5   Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
6   Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
,
Roopen Arya
7   Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital Foundation NHS Trust, London, United Kingdom
,
Kollengode Ramanathan‡   †
2   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
8   Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
,
Bingwen Eugene Fan‡   †
1   Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
2   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
9   Department of Haematology, Tan Tock Seng Hospital, Singapore, Singapore
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Abstract

The optimal pharmacological prophylaxis for venous thromboembolism (VTE) after hip or knee arthroplasty is uncertain. We conducted a systematic review and network meta-analysis to compare the efficacy and safety of various medications. We searched multiple databases for randomized clinical trials (RCTs) comparing medications (including factor Xa inhibitors, factor IIa inhibitor, warfarin, unfractionated heparin [UFH], low-molecular-weight heparin [LMWH], aspirin, pentasaccharide) for VTE prophylaxis post-arthroplasty. Outcomes included any postoperative VTE identified with screening, major bleeding, and death. We used LMWH as the main comparator for analysis and performed trial sequential analysis (TSA) for each pairwise comparison. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessments, Developments and Evaluations). We analyzed 70 RCTs (55,841 participants). Factor Xa inhibitors decreased postoperative VTE significantly compared with LMWH (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.44–0.68, high certainty). Pentasaccharides probably reduce VTE (OR: 0.61, 95% CI: 0.36–1.02, moderate certainty), while the factor IIa inhibitor dabigatran may reduce VTE (OR: 0.75, 95% CI: 0.40–1.42, low certainty). UFH probably increases VTE compared with LMWH (OR: 1.31, 95% CI: 0.91–1.89, moderate certainty), and other agents like warfarin, aspirin, placebo, and usual care without thromboprophylaxis increase VTE (high certainty). Factor Xa inhibitors may not significantly affect major bleeding compared with LMWH (OR: 1.06, 95% CI: 0.81–1.39, low certainty). No medications had a notable effect on mortality compared with LMWH (very low certainty). TSA suggests sufficient evidence for the benefit of factor Xa inhibitors over LMWH for VTE prevention. Compared with LMWH and aspirin, factor Xa inhibitors are associated with reduced VTE after hip or knee arthroplasty, without an increase in bleeding and likely no impact on mortality.

Keywords

meta-analysis - total hip or knee arthroplasty - venous thromboembolism

* Contributed equally as first authors.


† Contributed equally as senior authors.


Supplementary Material



Publication History

Article published online:
01 July 2024

© 2024. Thieme. All rights reserved.

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