What is the recommended duration and type of Deep Vein Thrombosis (DVT) prophylaxis for a 90-year-old male patient following hip replacement surgery, currently undergoing therapy at a skilled rehabilitation facility?

From the Guidelines

For a 90-year-old male patient recovering from hip replacement surgery in skilled rehabilitation, I recommend extended thromboprophylaxis for 28-35 days total with low molecular weight heparin (LMWH) such as enoxaparin 40mg subcutaneously once daily or 30 mg twice daily, as this has been shown to be effective in preventing DVT in patients undergoing orthopedic surgery 1. The patient's advanced age and the high DVT risk associated with hip replacement surgery necessitate extended prophylaxis.

• The preferred medication is LMWH, such as enoxaparin, due to its efficacy and safety profile in this patient population 1.
• Alternatively, direct oral anticoagulants (DOACs) like rivaroxaban 10mg daily can be used if the patient has normal renal function, as they have been shown to be noninferior to LMWH in preventing VTE 1.
• If these options aren't suitable, warfarin (target INR 2-3) or aspirin 81mg twice daily could be considered, though they may be less effective.
• Early mobilization through physical therapy should complement pharmacological prophylaxis to reduce the risk of DVT.
• Monitor for bleeding complications, especially given the patient's age, and assess renal function before prescribing as dose adjustments may be needed for enoxaparin or DOACs with impaired kidney function.
• Mechanical prophylaxis with compression devices should be used if pharmacological options are contraindicated. The American College of Chest Physicians (ACCP) guidelines, as summarized in the study 1, support the use of extended thromboprophylaxis in patients undergoing hip replacement surgery, particularly in those at high risk of DVT, such as the elderly.

From the FDA Drug Label

2.2 Deep Vein Thrombosis Prophylaxis Following Hip Fracture, Hip Replacement, and Knee Replacement Surgery In patients undergoing hip fracture, hip replacement, or knee replacement surgery, the recommended dose of fondaparinux sodium injection is 2.5 mg administered by subcutaneous injection once daily after hemostasis has been established. Administer the initial dose no earlier than 6 to 8 hours after surgery. Administration of fondaparinux sodium injection earlier than 6 hours after surgery increases the risk of major bleeding. The usual duration of therapy is 5 to 9 days; up to 11 days of therapy was administered in clinical trials

The recommended duration of DVT prophylaxis for a 90-year-old male patient following hip replacement surgery is 5 to 9 days, and the recommended type of prophylaxis is fondaparinux sodium injection 2.5 mg administered subcutaneously once daily 2.

• The initial dose should be administered no earlier than 6 to 8 hours after surgery.
• Fondaparinux sodium injection is the recommended medication for DVT prophylaxis in this context. Note that the patient's age and the fact that they are in a skilled rehabilitation facility do not affect the recommended duration or type of DVT prophylaxis according to the provided drug label.

From the Research

Recommended Duration and Type of DVT Prophylaxis

The recommended duration and type of Deep Vein Thrombosis (DVT) prophylaxis for a 90-year-old male patient following hip replacement surgery can be informed by several studies:

• The use of low-molecular-weight heparin (LMWH) is a standard anticoagulant therapy for prevention of thrombosis after hip or knee replacement surgery 3.
• A study comparing different doses of enoxaparin found that 40 mg once daily or 30 mg every 12 hours is more effective than 10 mg once daily to prevent DVT in patients having elective hip replacement surgery 4.
• Another study found that a regimen of fondaparinux and tranexamic acid can reduce the risk of bleeding complications while maintaining efficacy in preventing DVT 5.
• The combination of LMWH and intermittent pneumatic compression has been shown to be more effective than LMWH used with graduated compression stockings in preventing DVT after total hip or knee replacement 6.
• A pilot study suggested that intermittent compression devices can prevent deep venous thrombosis after hip surgery even when applied for short intervals over a short period of time 7.

Key Considerations

Some key considerations for DVT prophylaxis in this patient population include:

• The risk of bleeding complications, which may be higher in frail elderly patients 3.
• The need for monitoring of renal function, particularly when using certain anticoagulants such as rivaroxaban 3.
• The potential benefits of combining different methods of DVT prophylaxis, such as LMWH and intermittent pneumatic compression 6.
• The importance of individualizing DVT prophylaxis based on patient-specific factors, such as age, weight, and comorbidities 3, 4, 5, 6, 7.