What is the recommended thromboprophylaxis (thrombosis prevention) in orthopedic surgery for patients with thrombophilia (hypercoagulability disorder)?

From the Guidelines

Patients with thrombophilia undergoing orthopedic surgery should receive low-molecular-weight heparin (LMWH) as the preferred thromboprophylaxis, with the first dose given at least 12 hours from the time of surgery, and continued for a minimum of 10 to 14 days, with consideration of up to 35 days for patients at higher risk for VTE. This recommendation is based on the most recent and highest quality evidence available, which prioritizes the reduction of morbidity, mortality, and improvement of quality of life as the primary outcome 1.

Key Considerations

• The use of LMWH, such as enoxaparin, is supported by guidelines due to its effective thromboprophylaxis and relatively low risk of bleeding 1.
• For patients with severe thrombophilia, higher prophylactic doses of LMWH or even therapeutic anticoagulation may be considered, depending on individual risk assessment.
• Mechanical prophylaxis with intermittent pneumatic compression devices is recommended in addition to anticoagulant therapy, particularly for patients at high risk of bleeding 1.
• The duration of thromboprophylaxis should be tailored to the individual patient's risk, with a minimum of 10 to 14 days and consideration of up to 35 days for those at higher risk for VTE 1.

Management of Anticoagulation

• For patients already on long-term anticoagulation, bridge therapy with LMWH is essential, typically discontinuing warfarin 5 days before surgery and starting LMWH, then resuming warfarin postoperatively with LMWH overlap until therapeutic INR is achieved.
• Direct oral anticoagulants (DOACs) should be stopped 48-72 hours preoperatively, depending on renal function, and resumed when hemostasis is adequate.

Monitoring and Safety

• Close monitoring for both bleeding and thrombotic complications is crucial throughout the perioperative period.
• The choice of thromboprophylaxis should be guided by the patient's individual risk factors, including the type and severity of thrombophilia, as well as the presence of any bleeding disorders or other comorbidities.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Prophylaxis of DVT Following Hip or Knee Replacement Surgery: 10 mg orally once daily with or without food Known thrombophilic conditions (6%), Factor V Leiden gene mutation (4%), The recommended thromboprophylaxis in orthopedic surgery for patients with thrombophilia is 10 mg of rivaroxaban orally once daily.

• The dosage is the same for patients with known thrombophilic conditions, including Factor V Leiden gene mutation. 2

From the Research

Thromboprophylaxis in Orthopedic Surgery for Patients with Thrombophilia

• The use of antithrombotic drugs for the prevention of venous thromboembolism (VTE) in patients undergoing surgery is based on solid principles and high-level scientific evidence 3.
• Patients undergoing major orthopedic surgery have a particularly high risk of VTE, and routine thromboprophylaxis with low molecular weight heparin (LMWH), fondaparinux, or a vitamin K antagonist is the standard of care in this group of patients 3.
• Direct oral anticoagulants (DOACs) are increasingly being used as alternatives to LMWH for thromboprophylaxis in orthopedic surgery, and have been shown to be associated with a significant reduction of major VTE and deep vein thrombosis (DVT) compared to LMWH 4.
• The choice of thromboprophylaxis may depend on individual patient factors, such as the presence of thrombophilia or other bleeding disorders, and the type of surgery being performed 5, 6.
• Mechanical methods of thromboprophylaxis, such as compression stockings and intermittent pneumatic compression, may also be used in addition to pharmacological thromboprophylaxis, particularly in patients at high risk of bleeding 3.

Specific Considerations for Patients with Thrombophilia

• Patients with thrombophilia may require more aggressive thromboprophylaxis, such as the use of higher doses of anticoagulants or the addition of mechanical methods of thromboprophylaxis 5.
• The use of aspirin for thromboprophylaxis in patients with thrombophilia is not well established, but may be considered in certain situations, such as in patients who are at high risk of bleeding or who have a history of VTE 6.
• The risk of VTE in patients with thrombophilia undergoing orthopedic surgery is high, and thromboprophylaxis should be tailored to the individual patient's risk factors and medical history 3, 4.

Comparison of Thromboprophylaxis Options

• A meta-analysis of randomized controlled trials comparing DOACs with LMWH for thromboprophylaxis in orthopedic surgery found that DOACs were associated with a significant reduction of major VTE and DVT, but not pulmonary embolism, compared to LMWH 4.
• The safety outcomes of DOACs and LMWH were not significantly different, with no increase in major bleeding or clinically relevant non-major bleeding with DOACs compared to LMWH 4.
• The choice of thromboprophylaxis should be based on individual patient factors, such as the presence of thrombophilia or other bleeding disorders, and the type of surgery being performed 5, 3, 6.