What can substitute for aspirin for thromboprophylaxis in patients with sacral fractures?

Thromboprophylaxis Alternatives to Aspirin for Sacral Fractures

For patients with sacral fractures requiring thromboprophylaxis, low-molecular-weight heparin (LMWH), fondaparinux, rivaroxaban, or apixaban are recommended alternatives to aspirin. 1

First-Line Alternatives to Aspirin

• Low-Molecular-Weight Heparin (LMWH): Enoxaparin 40 mg subcutaneously once daily is the most extensively studied thromboprophylactic agent and is considered a first-line alternative to aspirin 1
• Fondaparinux: 2.5 mg subcutaneously daily can be used as an alternative, particularly in patients who cannot receive heparin products 1
• Direct Oral Anticoagulants (DOACs):
  • Rivaroxaban 10 mg daily is FDA-approved for VTE prophylaxis and can be used as an alternative 1, 2
  • Apixaban 2.5 mg twice daily is another option with good efficacy 1

Risk Stratification Approach

For patients with sacral fractures, risk stratification should guide thromboprophylaxis selection:

• High-risk patients (previous VTE, active cancer, prolonged immobilization, or multiple risk factors):

  • LMWH is preferred as first-line therapy 1
  • DOACs (rivaroxaban or apixaban) are acceptable alternatives 1

• Patients with high bleeding risk:

  • Mechanical prophylaxis with intermittent pneumatic compression devices until bleeding risk decreases 1
  • Once bleeding risk decreases, pharmacologic prophylaxis can be initiated 1

Duration of Thromboprophylaxis

• Minimum duration of 10-14 days is recommended for thromboprophylaxis 1
• Consider extending to 35 days for patients at higher risk for VTE 1
• For pelvic fractures specifically, prophylaxis should be continued for at least 7-10 days, with consideration for extending to 4 weeks post-discharge in high-risk patients 1

Important Clinical Considerations

• Recent evidence: The PREVENT CLOT trial (2023) demonstrated that aspirin was noninferior to LMWH for preventing death in patients with extremity or pelvic fractures, with similar rates of pulmonary embolism (1.49% in both groups) 3, 4
• Bleeding risk: When selecting an alternative to aspirin, consider that DOACs may have an increased bleeding risk in patients with upper gastrointestinal or genitourinary malignancies 1
• Renal function: For patients with renal impairment (CrCl <30 mL/min), dose adjustment or alternative agents may be required 2
• Cost considerations: Aspirin is significantly less expensive than LMWH or DOACs, which may influence decision-making when efficacy is similar 5, 6

Special Situations

• Patients already on antiplatelet therapy: For patients already on dual antiplatelet therapy who need VTE prophylaxis, mechanical prophylaxis should be the primary approach to avoid excessive bleeding risk 7
• Patients with contraindications to anticoagulants: Intermittent pneumatic compression devices are recommended when pharmacologic prophylaxis is contraindicated 1

Monitoring Recommendations

• Monitor for signs of bleeding or thrombosis throughout the treatment period 1
• For patients on LMWH with prolonged use, consider periodic platelet count monitoring to detect heparin-induced thrombocytopenia 1
• For patients on DOACs, no routine coagulation monitoring is required, but renal function should be assessed periodically 2