What are the current recommendations for Deep Vein Thrombosis (DVT) prophylaxis following hip replacement surgery?

From the Guidelines

Current recommendations for DVT prophylaxis after hip replacement typically involve a combination of pharmacological and mechanical methods for 10-35 days post-surgery. The primary recommendation is to use low molecular weight heparin (LMWH), such as enoxaparin 40 mg subcutaneously once daily, starting 12 hours after surgery, or fondaparinux, as these are supported by most guidelines, including the ACCP, ICS, SIGN, the French and the Brazilian guidelines 1. In addition to pharmacological methods, mechanical prophylaxis should be employed, including early mobilization, graduated compression stockings, and intermittent pneumatic compression devices, as stated by the ICS, which supports the use of Foot Impulse Technology (FIT) or Intermittent Pneumatic Compression (IPC) combined with Graduated Elastic Compression Stockings (GECS) as an effective means of thromboprophylaxis 1. Key points to consider for DVT prophylaxis after hip replacement surgery include:

• The use of pharmacological thromboprophylaxis with either heparin, fondaparinux, or VKA, with a recommended duration of 7 to 42 days for heparin, and from 10 to 35 days for fondaparinux 1
• The employment of mechanical prophylaxis, such as early mobilization, graduated compression stockings, and intermittent pneumatic compression devices
• The consideration of patient risk factors, such as previous DVT, obesity, or cancer, to determine the duration of prophylaxis, which can be up to 35 days for high-risk patients
• The potential use of mechanical prophylaxis alone for patients with contraindications to anticoagulants, such as high bleeding risk, although this is less effective than combined methods 1. The goal of these recommendations is to balance the risk of DVT with the risk of bleeding, acknowledging that hip replacement patients remain at elevated DVT risk for several weeks post-surgery due to reduced mobility and the pro-thrombotic effects of surgery.

From the FDA Drug Label

1. 5 Prophylaxis of Deep Vein Thrombosis Following Hip or Knee Replacement Surgery XARELTO is indicated for the prophylaxis of DVT, which may lead to PE in adult patients undergoing knee or hip replacement surgery.

2.1 Recommended Dosage in Adults Table 1: Recommended Dosage in Adults IndicationRenal Considerations *DosageFood/Timing † ... Hip Replacement Surgery§ CrCl ≥15 mL/min ‡10 mg once daily for 35 days, 6–10 hours after surgery once hemostasis has been establishedTake with or without food CrCl <15 mL/minAvoid Use

The current recommendations for Deep Vein Thrombosis (DVT) prophylaxis following hip replacement surgery are:

• Rivaroxaban (XARELTO) 10 mg once daily for 35 days, starting 6-10 hours after surgery once hemostasis has been established, for patients with CrCl ≥15 mL/min.
• Avoid use in patients with CrCl <15 mL/min. 2

From the Research

Current Recommendations for DVT Prophylaxis

The current recommendations for Deep Vein Thrombosis (DVT) prophylaxis following hip replacement surgery are based on several studies and guidelines.

• Low-molecular-weight heparin (LMWH) and oral anticoagulants are both recommended for venous thromboembolism prophylaxis after total hip replacement 3.
• Extended prophylaxis with LMWH reduces the frequency of postdischarge VTE by approximately two thirds after hip replacement 4.
• Non-Vitamin K antagonist oral anticoagulants (NOACs) are as effective as LMWHs in preventing VTE and can be used for two weeks after TKR and five weeks after THR - six weeks after TKR and THR to cover the at-risk period for VTE post-discharge 5.

Comparison of Prophylaxis Methods

• A study comparing enoxaparin (a low molecular weight heparin) with unfractionated heparin found that enoxaparin may decrease the risk of DVT and length of hospital stay 6.
• Another study found that LMWH prophylaxis was at least as effective as oral anticoagulants, but with a marked improvement in safety 3.
• The guidelines have points in common, including the recommendation to combine mechanical and pharmacological prophylaxis in patients who have suffered a previous VTE, and the promotion of early mobilisation of the patient 7.

Duration of Prophylaxis

• The American College of Chest Physicians (ACCP) recommends a minimum of 7 to 10 days of prophylaxis after hip and knee replacement, even if patients are discharged from the hospital within 7 days of surgery 4.
• Extended prophylaxis is expected to be of less benefit after knee than after hip replacement, and should be used after major orthopedic surgery in patients who have additional risk factors for VTE 4.
• Aspirin for VTE prophylaxis after TKR/THR has been controversial, and most of the evidence is reported from observational research 5.