In this episode, I’ll discuss rivaroxaban, then aspirin vs aspirin alone for thromboprophylaxis after total knee or hip arthroplasty.
While thromboembolic events after orthopedic surgeries like total knee and hip arthroplasty are significant, so too are bleeding events. The quest to balance bleeding and clotting risk in the post-op period is ongoing, and a group of authors recently published a multicenter randomized controlled trial in New England Journal of Medicine looking at rivaroxaban, then aspirin vs aspirin alone for thromboprophylaxis after total knee or hip arthroplasty.
Over 5000 patients were assigned to receive once-daily thromboprophylaxis with either 81 mg of aspirin or 10 mg of oral rivaroxaban for the first 5 days after total hip or total knee arthroplasty. All the patients then received further thromboprophylaxis with 81 mg of aspirin daily for 9 additional days after knee arthroplasty and for 30 additional days after hip arthroplasty. Patients were followed for 90 days for symptomatic venous thromboembolism (defined as proximal deep-vein thrombosis or pulmonary embolism), and for bleeding complications.
VTE occurred in 0.48% of patients in the aspirin alone group and 0.45% in the rivaroxaban group. This difference was not statistically significant, but it did meet the pre-specified margin for a finding of non-inferiority.
Major bleeding or clinically relevant nonmajor bleeding events occurred in 1.66% of the aspirin-alone group and in 2.04% of the rivaroxaban–aspirin group. This difference was not statistically significant.
The authors concluded:
After total hip and total knee arthroplasty, the use of aspirin alone was not inferior to a strategy of using rivaroxaban followed by aspirin for the prevention of symptomatic venous thromboembolism, with no clinically relevant difference in bleeding events.
With orthopedic surgeons typically having a keen focus on the complication of post-op bleeding, they are likely to combine the high quality of this study with the trend in lower bleeding events with aspirin alone and clinical experience that avoiding rivaroxaban means avoiding an antithrombotic more potent than aspirin altogether and desire to use the aspirin-alone strategy in as many of their patients as are appropriate.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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