What is the recommended duration of deep venous thrombosis (DVT) prophylaxis for a 68-year-old woman with a comminuted fracture of the left hip, who underwent total hip arthroplasty and is being discharged to rehabilitation?

From the Guidelines

The correct recommendation for DVT prophylaxis in this 68-year-old woman following total hip arthroplasty is to continue prophylaxis for 35 days (option C). After major orthopedic surgery, particularly hip replacement, patients remain at elevated risk for venous thromboembolism for several weeks after the procedure. Extended thromboprophylaxis for 35 days has been shown to significantly reduce the risk of symptomatic DVT and pulmonary embolism compared to shorter durations, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1. This patient has additional risk factors including advanced age and limited mobility during rehabilitation, which further increase her thrombotic risk.

The specific medication should be continued from what was started postoperatively, which commonly includes low molecular weight heparin, factor Xa inhibitors, or other anticoagulants at prophylactic dosing. While the patient recovers at rehabilitation, this extended prophylaxis will provide protection during the highest risk period following surgery, even after she regains some mobility. The benefit of extended prophylaxis in this scenario outweighs the bleeding risk for most patients undergoing total hip arthroplasty. A minimum duration of 10 to 14 days of thromboprophylaxis is recommended, with consideration of up to 35 days for patients at higher risk for VTE, as suggested by the Mayo Clinic Proceedings 1.

Key points to consider in this patient's management include:

• The use of pharmacologic agents or intermittent pneumatic compression devices (IPCD) for DVT prophylaxis
• The recommendation for extended prophylaxis in patients at higher risk for VTE, such as those with advanced age and limited mobility
• The importance of weighing the benefits of extended prophylaxis against the bleeding risk for each individual patient. In this case, given the patient's age, recent surgery, and upcoming rehabilitation, continuing DVT prophylaxis for 35 days is the most appropriate recommendation.

From the FDA Drug Label

XARELTO is indicated for the prophylaxis of DVT, which may lead to PE in adult patients undergoing knee or hip replacement surgery.

Table 1: Recommended Dosage in Adults IndicationRenal Considerations *DosageFood/Timing Hip Replacement Surgery§ CrCl ≥15 mL/min ‡10 mg once daily for 35 days, 6–10 hours after surgery once hemostasis has been established

The recommended duration of DVT prophylaxis with rivaroxaban for a patient undergoing hip replacement surgery is 35 days.

• The patient should continue DVT prophylaxis for 35 days as indicated in the drug label for hip replacement surgery.
• This is a standard recommendation for patients with normal renal function (CrCl ≥15 mL/min).
• The dosage is 10 mg once daily, taken with or without food, starting 6-10 hours after surgery once hemostasis has been established 2.

From the Research

DVT Prophylaxis Recommendations

The patient in question has undergone total hip arthroplasty and is at risk for deep venous thrombosis (DVT). According to the evidence, the following recommendations can be made for DVT prophylaxis:

• The American College of Chest Physicians recommends that patients undergoing hip or knee arthroplasty or hip fracture surgery receive thromboprophylaxis for a minimum of 10 days and up to 35 days 3.
• A study published in the New England Journal of Medicine found that one month of anticoagulant therapy with low-molecular-weight heparin (enoxaparin) is more effective than enoxaparin therapy given only during hospitalization for surgery in preventing venous thromboembolism after total hip replacement 4.
• Another study published in Thrombosis Research suggests that extended out-of-hospital low-molecular-weight heparin prophylaxis can safely reduce the prevalence of deep vein thrombosis, but may not be cost-effective for all patients 5.
• Other studies have also demonstrated the effectiveness of low-molecular-weight heparin in preventing DVT after total hip replacement, with varying dosing regimens 6, 7.

Duration of DVT Prophylaxis

Based on the evidence, the recommended duration of DVT prophylaxis for this patient is:

• At least 10 days, with consideration for extending up to 35 days 3.
• One month of anticoagulant therapy with low-molecular-weight heparin has been shown to be effective in preventing venous thromboembolism after total hip replacement 4.

Options for DVT Prophylaxis

The options for DVT prophylaxis are:

• Continue for 7 days: This option may not be sufficient, as the recommended duration of prophylaxis is at least 10 days 3.
• Continue for 35 days: This option is in line with the recommendations of the American College of Chest Physicians and may be effective in preventing venous thromboembolism after total hip replacement 3, 4.
• Continue until no longer immobile: This option is not specific and may not provide adequate protection against DVT.
• No further medication: This option is not recommended, as DVT prophylaxis is necessary to prevent venous thromboembolism after total hip replacement 3, 5, 4, 6, 7.