Patient compliance with new oral anticoagulants after major orthopaedic surgery: rivaroxaban and dabigatran compared with subcutaneous injection of fondaparinux

Post-discharge patient-reported non-adherence to aspirin compared to enoxaparin for venous thromboembolism prophylaxis after hip or knee arthroplasty

BACKGROUND

Aspirin and enoxaparin are commonly used for venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA) or total knee arthroplasty (TKA). The purpose of this study was to compare non-adherence after discharge to aspirin or enoxaparin following THA or TKA.

METHODS

A subset of participants in the CRISTAL study were selected for participation. Additional inclusion criteria were no preoperative anticoagulant use and discharge from hospital before the prophylaxis period ended. The first four consecutive patients from each arm at each participating hospital were planned to be recruited (planned sample size n = 248). A patient-reported adherence questionnaire was completed by telephone at 36-41 days after THA and at 15-20 days after TKA. The primary outcome was non-adherence. Secondary outcomes were number of missed doses and the reasons for non-adherence.

RESULTS

There were 178 participants included from 15 sites, less than planned explained by early stopping of trial recruitment. There was no significant between-group difference in patient-reported non-adherence: 24% (17/71) for aspirin, 30% (32/107) for enoxaparin, odds ratio = 1.4 (95% CI 0.7-2.9). The mean number of missed doses was 2.5 for aspirin and 3.4 for enoxaparin (mean difference = 0.9 doses, 95% CI -1.2 to 3.1). For aspirin, the most commonly reported reason for non-adherence was forgotten doses and for enoxaparin it was clinician-recommended change.

CONCLUSIONS

Rates of non-adherence and the number of missing doses were similar for patients regardless of drug prescribed. The most common reasons for non-adherence were unrelated to the mode of administration.

Effectiveness and safety of rivaroxaban for the prevention of thrombosis following total hip or knee replacement: A systematic review and meta-analysis

BACKGROUND

Prophylactic anticoagulant therapy is recommended to reduce the risk of venous thromboembolism (VTE) after total hip or knee arthroplasty, and has become the standard of care. Rivaroxaban is a novel oral medication that directly inhibits factor Xa for the prevention and treatment of thromboembolic conditions.

METHOD

A meta-analysis of randomized controlled trials (RCTs) was performed to determine the efficacy and safety of rivaroxaban after total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgery. We reviewed several databases including PubMed, the Cochrane Library, Embase and the US trial registry to detect appropriate RCTs for our meta-analysis. The primary efficacy outcome of this meta-analysis was the combination of any deep-vein thrombosis (DVT), non-fatal pulmonary embolism (PE), and death from any cause. The main safety outcome was bleeding events which included significant bleeding events, clinically relevant insignificant bleeding events, or minor events. Other end points were the number of patients who received blood transfusion the volume of transfused whole blood or red blood cells, and the volume of postoperative drainage.

RESULT

Thirteen RCTs were included in this meta-analysis. This meta-analysis showed that the overall rate of VTE events, DVT, PE, and death were 1%, 6%, < 1% and < 1%, respectively, for patients receiving treatment with rivaroxaban after THA and TKA surgery. The subgroup analysis demonstrated rivaroxaban had more superior effects in THA patients. The pooled analysis of bleeding events showed that the overall rate of major bleeding events, overt bleeding events associated with fall in Hb of > 2 g/DL, clinically overt bleeding events leading to transfusion of > 2 units of blood, clinically overt bleeding events leading to further surgeries, and non-major bleeding events were < 1%, < 1%, < 1%, < 1%, and 3%, respectively.

CONCLUSION

This is the first systematic review of the literature providing incidence of efficacy and safety outcomes for thromboprophylaxis in THA and TKA patients. Moreover, this meta-analysis showed that rivaroxaban had more superior effect in THA patients.

Aspirin: are patients actually taking it?-A quality assessment study

BACKGROUND

The purpose of the study was to assess patient adherence to an aspirin-based prophylactic deep venous thromboembolism (DVT) care management plan after total lower extremity arthroplasty.

METHODS

Using a cross-sectional study design, patients who underwent total hip or knee replacement surgery by a single senior surgeon were surveyed at their routine 6-week follow-up appointment regarding adherence to aspirin DVT prophylaxis. Postoperatively, patients were advised to take 325 mg of aspirin twice daily for 6 weeks to prevent DVT.

RESULTS

Of the 101 patients surveyed, 45 underwent total hip arthroplasty while 56 underwent total knee arthroplasty. There were 48 (48%) patients who were still taking aspirin at their routine 6-week postoperative follow-up appointment and 53 (52%) patients who were not taking aspirin (nonadherent group). Of the latter, 3 (6%) never took aspirin postoperatively, 14 (26%) discontinued within 2 weeks postoperatively, and 23 (43%) did not take it any longer for half the time prescribed. In the nonadherent group, 8 patients reported that they felt they did not need the aspirin prophylaxis, 5 experienced side effects, and 10 were unsure of how long they needed to take it. There was 1 patient with a calf DVT and no episodes of pulmonary embolism.

CONCLUSIONS

Over half of our study, patients did not finish their aspirin regimen. We suggest a consistent outline of medication duration throughout the pre/postop course and communication regarding aspirin cessation.

Rivaroxaban and early periprostethic joint infection: our experience

BACKGROUND AND AIM OF THE WORK

Periprostethic joint infection (PJI) is a severe post-operative complication after Primary Total Hip Arthroplasty (THA). According to the classification of PJI early acute PJI occurs within 4 weeks from surgery. Some authors think that Rivaroxaban is a risk factor in the incidence of early acute PJI. We analyze our experience about this item.

MATERIALS AND METHODS

We analyze our experience from 1st January 2015 to 31th December 2016. We consider all consecutive hip arthroplasty implants in this period.

RESULTS

In the 205 patients analysed we not find early acute PJI in Rivaroxaban group nor in the others assuming another kind of thromboprophylaxis.

CONCLUSIONS

In our series there is no evidence of association between Rivaroxaban and early acute PJI. This is a retrospective cohort study, so we need more studies and more robust experimental designs to confirm these results.

Rivaroxaban and early periprostethic joint infection: our experience

BACKGROUND AND AIM OF THE WORK

Periprostethic joint infection (PJI) is a severe post-operative complication after Primary Total Hip Arthroplasty (THA). According to the classification of PJI early acute PJI occurs within 4 weeks from surgery. Some authors think that Rivaroxaban is a risk factor in the incidence of early acute PJI. We analyze our experience about this item.

MATERIALS AND METHODS

We analyze our experience from 1st January 2015 to 31th December 2016. We consider all consecutive hip arthroplasty implants in this period.

RESULTS

In the 205 patients analysed we not find early acute PJI in Rivaroxaban group nor in the others assuming another kind of thromboprophylaxis.

CONCLUSIONS

In our series there is no evidence of association between Rivaroxaban and early acute PJI. This is a retrospective cohort study, so we need more studies and more robust experimental designs to confirm these results.