What is the optimal anticoagulation (Anti-Coagulant) management strategy for patients with hip fracture prior to surgical intervention?

From the Guidelines

For patients with hip fractures on anticoagulation awaiting surgery, the management strategy should prioritize the use of semuloparin or enoxaparin for thromboprophylaxis, with semuloparin being a potentially favorable option due to its efficacy in reducing venous thromboembolism (VTE) or all-cause mortality by almost one-third compared to enoxaparin, as demonstrated in the SAVE-HIP trials 1. When considering anticoagulation management prior to surgery for hip fracture patients, it is crucial to weigh the risks of thrombosis against the risks of bleeding. The use of anticoagulants like semuloparin and enoxaparin has been studied in the context of major orthopedic surgery, including hip fracture repair.

• Key considerations include:
  • The dose and timing of anticoagulant administration, with semuloparin being administered at 20 mg once daily and enoxaparin at 40 mg once daily starting 12 hours prior to surgery 1.
  • The duration of anticoagulant therapy, which may extend beyond the initial 7-10 days to further reduce the risk of VTE or all-cause mortality, as seen in the SAVE-HIP3 trial where extended semuloparin therapy was beneficial 1.
  • The balance between the efficacy of anticoagulation in preventing VTE and the risk of major or clinically relevant nonmajor bleeding, which was found to be similar between semuloparin and enoxaparin in the meta-analysis of the SAVE-HIP1, 2, and SAVE-KNEE trials 1. Given the evidence from the SAVE-HIP trials, semuloparin appears to be a viable option for thromboprophylaxis in patients undergoing hip fracture surgery, offering a reduction in VTE or all-cause mortality without a significant increase in bleeding risk compared to enoxaparin 1. However, the decision to use semuloparin or another anticoagulant should be made on a case-by-case basis, considering the individual patient's risk factors for thrombosis and bleeding, as well as the timing and nature of the surgical procedure.

From the FDA Drug Label

The rates of major bleeding events reported during 3 active-controlled peri-operative VTE prophylaxis trials with enoxaparin sodium in hip fracture, hip replacement, or knee replacement surgery (N = 3,616) and in an extended VTE prophylaxis trial (n = 327) with fondaparinux sodium 2.5 mg are provided in Table 2. In this analysis, the incidences of major bleeding were as follows: <4 hours was 4.8% (5/104), 4 to 6 hours was 2.3% (28/1,196), 6 to 8 hours was 1.9% (38/1,965).

The management of anticoagulation prior to surgery for hip fracture involves careful consideration of the timing of the first injection of fondaparinux sodium after surgical closure.

• The incidence of major bleeding is highest when fondaparinux sodium is administered less than 4 hours after surgical closure, with a rate of 4.8%.
• The rates of major bleeding decrease as the time interval between surgical closure and fondaparinux sodium administration increases, with rates of 2.3% and 1.9% for administration 4 to 6 hours and 6 to 8 hours after surgical closure, respectively 2.

From the Research

Anticoagulation Management in Hip Fracture Patients

• The management of anticoagulation in patients with hip fractures is crucial to prevent bleeding complications and ensure timely surgery 3, 4, 5.
• A study published in the Journal of Orthopaedic Trauma found that patients on warfarin had similar transfusion rates and complication rates compared to non-anticoagulated patients, but had significantly longer time to surgery 3.
• Another study published in Injury found that urgent surgical care for anticoagulated hip fracture patients within 24 hours was not associated with severe bleeding complications, and that the transfusion rate was dependent on duration of surgery, preoperative hemoglobin level, and anticoagulation with direct oral anticoagulants (DOACs) 4.

Comparison of Anticoagulants

• A study published in Orthopaedic Surgery compared the efficacy and safety of aspirin and rivaroxaban for prevention of venous thromboembolism after hip fracture surgery, and found that aspirin was equivalent to rivaroxaban in terms of efficacy and safety 6.
• The study suggested that aspirin may be an effective, safe, and convenient alternative for extended prophylaxis after hip fracture surgery 6.

Surgical Treatment and Rehabilitation

• Hip fractures are typically treated surgically, unless the patient has significant comorbidities or reduced life expectancy 7.
• Patients should receive prophylactic antibiotics and thromboembolic prophylaxis before surgery, and rehabilitation is critical to long-term recovery 7.
• A study published in the Journal of the American Geriatrics Society found that active management of anticoagulation in a geriatric fracture center model may facilitate earlier surgery without increasing observed complications 5.

Outcomes and Complications

• A study published in the Journal of Orthopaedic Trauma found that patients on warfarin had similar outcomes and complication rates compared to non-anticoagulated patients, but had longer time to surgery and longer length of stay 3.
• Another study published in Injury found that in-patient mortality was dependent on a high ASA classification and time to surgery, but not on the type of antithrombotic therapy 4.
• The study also found that postoperative haematoma and the need for transfusion were manageable situations, and that immediate surgical treatment of hip fracture patients on long-term antithrombotic therapy within 24 hours was feasible 4.