What is the treatment for Deep Vein Thrombosis (DVT) after total knee arthroplasty (TKA)?

From the Guidelines

For post-operative deep vein thrombosis (DVT) treatment following total knee arthroplasty, therapeutic anticoagulation with direct oral anticoagulants (DOACs) such as rivaroxaban or apixaban is recommended. The standard approach involves transitioning to oral anticoagulants after initial treatment with low molecular weight heparin (LMWH) such as enoxaparin. According to the American Society of Hematology 2020 guidelines 1, DOACs are preferred for most patients due to their reduced risk of bleeding compared to vitamin K antagonists (VKAs).

Treatment Options

• Rivaroxaban 15 mg twice daily for 21 days followed by 20 mg daily
• Apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily
• Edoxaban 60 mg daily (30 mg if CrCl 15-50 mL/min or weight ≤60 kg) Warfarin is an alternative, targeting INR 2-3, but it is not the first choice due to the higher risk of bleeding and the need for regular monitoring.

Key Considerations

• Treatment duration should be at least 3 months
• Monitor for bleeding complications and ensure adequate pain control with medications that don't increase bleeding risk
• Compression stockings may help reduce swelling
• Early mobilization should be encouraged as tolerated The anticoagulation prevents clot propagation and reduces the risk of pulmonary embolism by inhibiting thrombin formation or directly inhibiting factor Xa, allowing the body's natural fibrinolytic system to gradually dissolve the existing clot. It is essential to consider individual patient factors, such as renal and hepatic function, medication interactions, and patient preference, when selecting an anticoagulant therapy 1.

From the FDA Drug Label

In the REgulation of Coagulation in ORthopedic Surgery to Prevent DVT and PE, Controlled, Double-blind, Randomized Study of BAY 59-7939 in the Extended Prevention of VTE in Patients Undergoing Elective Total Hip or Knee Replacement (RECORD 1,2, and 3) [NCT00329628, NCT00332020, NCT00361894] studies One randomized, double-blind, clinical study (RECORD 3) in patients undergoing elective total knee replacement surgery compared XARELTO 10 mg once daily started at least 6 to 8 hours (about 90% of patients dosed 6 to 10 hours) after wound closure versus enoxaparin.

For post-operative total knee arthroplasty DVT treatment, the recommended dose of rivaroxaban is 10 mg once daily started at least 6 to 8 hours after wound closure 2.

• The RECORD 3 study compared rivaroxaban 10 mg once daily to enoxaparin in patients undergoing elective total knee replacement surgery.
• Rivaroxaban was shown to be effective in reducing the risk of DVT and PE in these patients.
• The mean exposure duration to active rivaroxaban was 11 days in the RECORD 3 study.
• Rivaroxaban is a factor Xa inhibitor that works by inhibiting thrombin generation and thrombus development.
• It is not necessary to monitor the anticoagulation effect of rivaroxaban with clotting tests such as prothrombin time (PT), INR, and activated partial thromboplastin time (aPTT).

From the Research

Post-Op Total Knee Arthroplasty DVT Treatment

• The treatment of Deep Vein Thrombosis (DVT) after total knee arthroplasty (TKA) is crucial to prevent complications such as pulmonary embolism (PE) and death.
• Several studies have compared the efficacy and safety of different thromboprophylaxis agents, including enoxaparin, warfarin, apixaban, and rivaroxaban 3, 4, 5.
• A study published in 2000 found that adjusted-dose warfarin was associated with a lower incidence of bleeding complications compared to enoxaparin, although the incidence of DVT was similar in both groups 3.
• Another study published in 2016 found that apixaban was associated with a lower incidence of VTE and bleeding complications compared to enoxaparin 4.
• A meta-analysis published in 2013 found that oral factor Xa inhibitors (apixaban and rivaroxaban) were superior to enoxaparin in preventing DVT, but not in preventing PE or death 5.
• A systematic review published in 2024 found that aspirin, enoxaparin, and dabigatran had an overall satisfactory efficacy and safety profile for VTE prophylaxis after hip and knee arthroplasty 6.
• A review published in 2020 found that aspirin has emerged as a promising prophylactic agent for patients undergoing arthroplasty due to its similar efficacy and good safety profile compared to other pharmacologic agents 7.

Comparison of Thromboprophylaxis Agents

• Enoxaparin and warfarin have been compared in several studies, with mixed results 3, 4.
• Apixaban and rivaroxaban have been shown to be effective in preventing DVT, but not in preventing PE or death 4, 5.
• Aspirin has been found to have a similar efficacy and good safety profile compared to other pharmacologic agents 6, 7.
• Dabigatran has been found to have an overall satisfactory efficacy and safety profile for VTE prophylaxis after hip and knee arthroplasty 6.

Safety and Efficacy Outcomes

• The primary efficacy outcome of interest is the risk of VTE, while the primary safety outcomes of interest are the risk of major bleeding events (MBE) and wound complications (WC) 6.
• The incidence of VTE after TKA has been found to be approximately 0.6-1.5% 7.
• The rate of VTE after TKA has been stable over the past decade, although there has been a slight reduction in the rate of DVT, but not PE 7.