From the Guidelines
Deep vein thrombosis (DVT) prophylaxis following total knee replacement should include both pharmacological and mechanical methods, with the recommended pharmacological options being low molecular weight heparin (LMWH) such as enoxaparin 30mg subcutaneously twice daily, or direct oral anticoagulants (DOACs) like rivaroxaban 10mg orally once daily, as supported by the most recent and highest quality study 1. The recommended pharmacological options for DVT prophylaxis following total knee replacement include:
- Low molecular weight heparin (LMWH) such as enoxaparin 30mg subcutaneously twice daily, starting 12 hours before or after surgery and continuing for 10-14 days, with consideration of extension up to 35 days for high-risk patients 1
- Direct oral anticoagulants (DOACs) like rivaroxaban 10mg orally once daily, starting 6-10 hours after surgery and continuing for 10-14 days, with consideration of extension up to 35 days for high-risk patients 1 Mechanical prophylaxis should include:
- Early mobilization
- Graduated compression stockings
- Intermittent pneumatic compression devices starting immediately after surgery until the patient is fully mobile For patients with contraindications to anticoagulants, mechanical prophylaxis alone should be used. These measures are crucial because total knee replacement surgery significantly increases the risk of DVT due to venous stasis, endothelial injury during surgery, and a hypercoagulable state from the inflammatory response to surgery. Extended prophylaxis beyond hospital discharge is particularly important as the risk of DVT remains elevated for several weeks after surgery. It is essential to note that the choice of pharmacological agent and duration of prophylaxis should be individualized based on patient risk factors and clinical judgment.
From the FDA Drug Label
- 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 † ... Knee Replacement Surgery§ CrCl ≥15 mL/min ‡10 mg once daily for 12 days, 6–10 hours after surgery once hemostasis has been establishedTake with or without food CrCl <15 mL/minAvoid Use
The recommended DVT prophylaxis following total knee replacement is 10 mg of rivaroxaban once daily for 12 days, starting 6-10 hours after surgery once hemostasis has been established, in patients with a CrCl ≥15 mL/min 2.
From the Research
Recommended DVT Prophylaxis
The recommended Deep Vein Thrombosis (DVT) prophylaxis following total knee replacement includes:
- Low-molecular-weight heparin (LMWH) which has been studied extensively and provides highly effective and safe prophylaxis against DVT 3, 4
- A synthetic pentasaccharide (fondaparinux) which received an A1 rating in the American College of Chest Physicians recommendations 3
- Direct oral Xa inhibitors which had a favorable profile compared with low-molecular-weight heparin in terms of VTE and hemorrhage risk 5
Administration and Efficacy
- LMWH can be started before surgery or after surgery and is given by subcutaneous injection 3
- The prevalence of DVT with LMWH prophylaxis was 33% in TKA data pooled from six randomized studies, with a proximal DVT rate of 7.1% 3
- A meta-analysis reported a 2.4% rate of major bleeding with LMWH 3
- Combined prophylaxis with LMWH and intermittent pneumatic compression is more effective than LMWH used with graduated compression stockings 6
Comparison of Prophylaxis Options
- Direct oral Xa inhibitors had the lowest risk of total deep vein thrombosis (DVT)-asymptomatic and symptomatic- compared to LMWH 5
- Vitamin K antagonists (VKAs) titrated to International Normalized Ratio [INR] 2-3 predicted 56% more DVT events compared to LMWH 5
- Aspirin performed similarly to LMWH, although small numbers prohibit firm conclusions 5