What are the Deep Vein Thrombosis (DVT) prophylaxis guidelines for the orthopedic post-operative period?

From the Guidelines

DVT prophylaxis for orthopedic post-operative patients should involve a combination of mechanical and pharmacological methods, with Low Molecular Weight Heparin (LMWH) being the preferred pharmacological agent due to its effective thromboprophylaxis and low risk of bleeding, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1.

Recommended Regimen

• Mechanical prophylaxis: Early mobilization and graduated compression stockings or intermittent pneumatic compression devices, starting immediately post-op.
• Pharmacological prophylaxis:
  • Low molecular weight heparin (LMWH): e.g., Enoxaparin 40 mg subcutaneously once daily, starting 12 hours post-op
  • OR
  • Direct oral anticoagulants (DOACs): e.g., Apixaban 2.5 mg orally twice daily, starting 6-10 hours post-op, which has been shown to have similar or superior properties of effective thromboprophylaxis combined with little risk of bleeding 1.

Duration

• Hip arthroplasty: 35 days
• Knee arthroplasty: 10-14 days
• Hip fracture surgery: 28-35 days For patients with high bleeding risk, consider using aspirin 81 mg twice daily instead of LMWH or DOACs. These measures are crucial because orthopedic surgeries, especially those involving the lower extremities, significantly increase the risk of deep vein thrombosis (DVT) due to immobilization, tissue trauma, and activation of the coagulation cascade, and extending thromboprophylaxis up to 35 days results in an additional reduction of symptomatic VTE with a similar safety profile 1.

From the FDA Drug Label

1. 4 Prophylaxis of Deep Vein Thrombosis Following Hip or Knee Replacement Surgery XARELTO was studied in 9011 patients (4487 XARELTO-treated, 4524 enoxaparin-treated patients) 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 The two randomized, double-blind, clinical studies (RECORD 1 and 2) in patients undergoing elective total hip replacement surgery compared XARELTO 10 mg once daily starting at least 6 to 8 hours (about 90% of patients dosed 6 to 10 hours) after wound closure versus enoxaparin 40 mg once daily started 12 hours preoperatively 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.

The DVT prophylaxis guidelines for the orthopedic post-operative period are as follows:

• For patients undergoing elective total hip replacement surgery, XARELTO 10 mg once daily starting at least 6 to 8 hours after wound closure is recommended.
• For patients undergoing elective total knee replacement surgery, XARELTO 10 mg once daily starting at least 6 to 8 hours after wound closure is recommended. Key points:
• The recommended dosage is 10 mg once daily.
• The treatment should be started at least 6 to 8 hours after wound closure.
• The studies compared XARELTO to enoxaparin 40 mg once daily started 12 hours preoperatively 2.

From the Research

DVT Prophylaxis Guidelines

The guidelines for Deep Vein Thrombosis (DVT) prophylaxis in the orthopedic post-operative period are as follows:

• The American College of Chest Physicians (ACCP) recommends the use of either low-molecular-weight heparin (LMWH), fondaparinux, or adjusted-dose warfarin as preferred VTE prophylaxis in patients undergoing either hip or knee arthroplasty 3.
• Fondaparinux is the preferred recommendation for patients undergoing hip fracture repair, followed by LMWH, unfractionated heparin, and adjusted-dose warfarin as alternative options 3.
• Extended-duration prophylaxis (for 4 to 5 weeks) is now recommended for patients undergoing hip arthroplasty or hip fracture repair 3, 4.
• Aspirin combined with mechanical devices can be used for VTE prophylaxis in patients after orthopedic surgery, with a comparable risk of DVT to LMWH 5.

Pharmacological Measures

Pharmacological measures for DVT prophylaxis include:

• Low dose unfractionated heparin
• Low molecular weight heparin (LMWH)
• Fondaparinux
• Newer oral anticoagulants, such as dabigatran, rivaroxaban, and apixiban 6
• Aspirin, which can be used in combination with mechanical devices 5

Non-Pharmacological Measures

Non-pharmacological measures for DVT prophylaxis include:

• Intermittent pneumatic compression device (IPCD)
• Graduated compression stockings
• Mechanical devices
• Inferior caval vein filters 6

Duration of Prophylaxis

The duration of VTE prophylaxis after surgery is:

• A minimum of 7 to 10 days of prophylaxis after hip and knee replacement 4
• Extended prophylaxis (for 4 to 5 weeks) is recommended for patients undergoing hip arthroplasty or hip fracture repair 3, 4