From the Guidelines
For patients who refuse intravenous (IV) medication, low molecular weight heparin (LMWH) is a good post-surgical prophylaxis option, as it can be administered subcutaneously and has been shown to be effective in preventing venous thromboembolism (VTE) in patients undergoing surgery. According to the most recent and highest quality study, patients who are candidates for extended pharmacologic thromboprophylaxis after surgery may be offered prophylactic doses of LMWH 1. This recommendation is based on high-quality evidence and has a strong strength of recommendation.
Alternatively, patients may be offered prophylactic doses of rivaroxaban or apixaban after an initial period of LMWH or unfractionated heparin (UFH), but the evidence for these options is limited and the strength of recommendation is weak 1. It's essential to consider the specific surgery type, patient risk factors, and local guidelines when selecting a post-surgical prophylaxis option.
Some key points to consider when using LMWH for post-surgical prophylaxis include:
- Administering the first dose 2-4 hours before surgical incision to ensure adequate levels during the procedure
- Continuing prophylaxis for at least 7 to 10 days, and up to 4 weeks post-operatively for high-risk patients 1
- Monitoring patients for signs and symptoms of VTE, as well as bleeding complications
- Adjusting the dose and duration of prophylaxis based on patient-specific factors, such as renal function and bleeding risk.
From the FDA Drug Label
2 DOSAGE AND ADMINISTRATION
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 § 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
A good post-surgical prophylaxis medication for a patient who refuses intravenous (IV) medication is rivaroxaban (PO), which can be taken orally.
- The recommended dosage for hip replacement surgery is 10 mg once daily for 35 days, starting 6-10 hours after surgery once hemostasis has been established.
- The recommended dosage for knee replacement surgery is 10 mg once daily for 12 days, starting 6-10 hours after surgery once hemostasis has been established.
- It can be taken with or without food. 2
From the Research
Post-Surgical Prophylaxis Options
For patients who refuse intravenous (IV) medication, there are several post-surgical prophylaxis options available.
- Direct Oral Anticoagulants (DOACs) such as dabigatran, apixaban, rivaroxaban, and edoxaban have shown promising results in clinical trials for post-operative venous thromboembolism (VTE) prophylaxis 3.
- Apixaban, in particular, has been found to be a safe and effective option for VTE prophylaxis after major orthopedic surgery, with a lower risk of bleeding compared to traditional anticoagulants 4, 5, 6.
- A study comparing apixaban to enoxaparin for thromboprophylaxis after hip replacement found that apixaban was associated with lower rates of venous thromboembolism without increased bleeding 6.
- Another study found that apixaban resulted in a lower VTE incidence and fewer hemorrhagic complications compared to enoxaparin in patients undergoing total knee arthroplasty 5.
Benefits of DOACs
The use of DOACs for post-surgical prophylaxis offers several benefits, including: