What is the recommended Direct Oral Anticoagulant (DOAC) for Deep Vein Thrombosis (DVT) prophylaxis after Open Reduction Internal Fixation (ORIF) surgery?

DOAC Selection for DVT Prophylaxis After ORIF Surgery

For DVT prophylaxis after ORIF surgery, apixaban 2.5 mg twice daily is the recommended DOAC, starting 12-24 hours after surgery and continuing for 35 days after hip ORIF or 14 days after knee ORIF. 1

Recommended DOAC Options and Dosing

Primary Recommendation:

• Apixaban (Eliquis)
  • Dosage: 2.5 mg twice daily
  • Timing: Start 12-24 hours after surgery (once hemostasis is achieved)
  • Duration:
    • 35 days for hip ORIF
    • 14 days for knee ORIF

Alternative Options:

1. Rivaroxaban (Xarelto)

   • Dosage: 10 mg once daily
   • Duration:
     • 28-35 days for hip ORIF
     • 10-14 days for knee ORIF

2. Dabigatran (Pradaxa)

   • Dosage: 220 mg once daily (or 150 mg once daily if CrCl 30-50 mL/min, P-gp inhibitors, age >75 years)
   • Duration: Similar to rivaroxaban

3. Edoxaban (Lixiana/Savaysa)

   • Less commonly used for this indication

Factors Affecting DOAC Selection

Patient-Specific Considerations:

• Renal function:

  • Apixaban and rivaroxaban are preferred if CrCl <50 mL/min
  • Dabigatran requires dose reduction if CrCl 30-50 mL/min
  • Avoid all DOACs if CrCl <15 mL/min

• Age and weight:

  • For patients ≥80 years or ≤60 kg, consider dose adjustments
  • Apixaban dose adjustment if patient meets 2 of 3 criteria: age ≥80 years, weight ≤60 kg, or creatinine ≥133 μmol/L

• Drug interactions:

  • Check for P-glycoprotein inhibitors (affects all DOACs)
  • Check for CYP3A4 inhibitors (affects rivaroxaban and apixaban)

Perioperative Management

Preoperative Assessment:

• Evaluate baseline renal function
• Check for drug interactions
• Assess bleeding risk factors

Postoperative Initiation:

• Ensure surgical hemostasis is achieved
• Wait minimum 6 hours after end of procedure
• For patients with epidural catheters, delay DOAC initiation until after catheter removal 2

Transitioning from Prophylactic Heparin:

• If initial prophylaxis with LMWH is used, administer first DOAC dose 12 hours after last LMWH dose
• Avoid overlapping anticoagulants 1

Common Pitfalls to Avoid

1. Premature initiation: Starting DOAC before adequate hemostasis is achieved
2. Inappropriate dosing: Using treatment doses instead of prophylactic doses
3. Inadequate duration: Stopping prophylaxis too early, especially after hip ORIF
4. Failure to adjust for renal function: Not checking or monitoring creatinine clearance
5. Drug interactions: Not accounting for medications that affect DOAC metabolism
6. Neuraxial anesthesia concerns: Using DOACs too soon before/after epidural catheter placement/removal

Special Considerations

• For patients with very high bleeding risk, consider delaying DOAC initiation and using prophylactic doses of LMWH temporarily
• For patients with epidural catheters, use heparin for anticoagulation until safe catheter removal 2, 1
• Monitor renal function postoperatively and adjust DOAC dosing if renal function changes

The evidence strongly supports DOACs as first-line therapy for DVT prophylaxis after orthopedic surgery, with apixaban showing a favorable efficacy and safety profile 1, 3.