From the Guidelines
The optimal DVT prophylaxis after total knee arthroplasty typically involves either low molecular weight heparin (LMWH) such as enoxaparin 40mg subcutaneously once daily, or direct oral anticoagulants (DOACs) such as rivaroxaban 10mg orally once daily or apixaban 2.5mg orally twice daily. Prophylaxis should be continued for 10-14 days after surgery, though extended prophylaxis for up to 35 days may be beneficial for high-risk patients 1. Early mobilization and mechanical prophylaxis with intermittent pneumatic compression devices should also be implemented. Aspirin 81mg twice daily is an acceptable alternative for patients at lower risk of VTE. The choice between agents should consider patient-specific factors including renal function, bleeding risk, medication interactions, and cost. These medications work by inhibiting different parts of the coagulation cascade, preventing the formation of blood clots in the deep veins of the legs during the postoperative period when patients have reduced mobility and increased hypercoagulability due to surgical trauma. Proper timing of the first dose is important - typically 12-24 hours after surgery when hemostasis is established to balance thromboprophylaxis with bleeding risk 1. Some key points to consider when choosing a prophylactic agent include:
- The patient's risk of bleeding and VTE
- The patient's renal function and potential for medication interactions
- The cost and availability of the medication
- The patient's ability to adhere to the prescribed regimen It is also important to note that mechanical prophylaxis with intermittent pneumatic compression devices can be used in addition to pharmacologic prophylaxis, and may be particularly useful in patients at high risk of bleeding 1. Overall, the choice of DVT prophylaxis after total knee arthroplasty should be individualized based on the patient's specific risk factors and needs.
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 optimal DVT prophylaxis after total knee arthroplasty 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
Optimal DVT Prophylaxis after Total Knee Arthroplasty
The optimal Deep Vein Thrombosis (DVT) prophylaxis after total knee arthroplasty is a topic of ongoing research and debate. Several studies have investigated the efficacy and safety of different prophylactic agents, including low-molecular-weight heparin (LMWH), aspirin, and newer oral anticoagulants.
Prophylactic Agents
- Low-molecular-weight heparin (LMWH): Studies have shown that LMWH is a highly effective and safe prophylactic agent against DVT after total knee arthroplasty 3, 4, 5. The prevalence of DVT with LMWH prophylaxis was found to be around 30-33% 3, 5.
- Aspirin: Aspirin has been found to be a suitable alternative to LMWH for patients with standard VTE risk profile 6. A study found no significant difference in the incidence of DVT between aspirin and LMWH 7.
- Newer oral anticoagulants: These agents, including rivaroxaban, have been found to be effective in reducing postoperative VTE, but may be associated with increased bleeding and wound complication rates 7, 6.
Safety and Efficacy
- The safety and efficacy of LMWH have been well established, with a predictable dose response and low risk of major bleeding 3, 5.
- Aspirin has been found to have a relatively low bleeding risk and is cost-effective 6.
- Newer oral anticoagulants, such as rivaroxaban, have been found to have a higher incidence of hidden blood loss and wound complications compared to LMWH and aspirin 7.