OC 66.4 - Pharmacotherapy for venous thromboprophylaxis following total hip or knee arthroplasty: a systematic review and network meta-analysis

Tuesday, June 25, 2024

15:30 – 15:45 ICT

Room: 111 A-C

Co-Author(s)

BY

Bryan Song Jun Yong

Medical Student
Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
Singapore, Singapore
RL

Ryan Ruiyang Ling

House Officer
Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
Singapore, Singapore
RL

Ruiqi Li

Medical Student
Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
Singapore, Singapore
JP

Jane Wenjin Poh

Medical Student
Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
Singapore, Singapore
CT

Chuen Seng Tan

Assistant Professor
Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore
Singapore, Singapore
SH

Sean Wei Loong Ho

Consultant Orthopaedic Surgeon
Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
Singapore, Singapore
BR

Bram Rochwerg

Associate Professor
Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
Hamilton, Ontario, Canada
Roopen Arya

Professor of Thrombosis and Haemostasis at King's College London
King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, London, UK
London, England, United Kingdom
KR

Kollengode Ramanathan

Associate Professor and Adult Cardiac Intensivist
Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore.
singapore, Singapore

Presenting Author(s)

Bingwen Eugene Fan, MBBS, MRCP, MMED

Consultant Haematologist
Department of Haematology, Tan Tock Seng Hospital, Singapore
Singapore, Singapore

Background: The optimal choice for pharmacological prophylaxis of venous thromboembolism (VTE) after hip or knee arthroplasty remains unclear.

Aims: The aim of this systematic review and network meta-analysis was to summarize the efficacy and safety of pharmacological agents in patients following elective hip and knee arthroplasty.

Methods: We searched Medline, Embase, and Scopus databases from inception through 13 October 2023, and clinicaltrials.gov(unpublished data) for randomised clinical trials(RCTs) comparing medications (including factor Xa inhibitors, factor IIa inhibitors, warfarin, unfractionated heparin[UFH], low molecular weight heparin [LMWH], aspirin and pentasaccharides) or placebo, or control used for VTE in patients following elective total hip or knee arthroplasty. The primary outcome was VTE, and secondary outcomes included major bleeding and death. We conducted frequentist random-effects network meta-analysis using LMWH as the main comparator for analysis, and for VTE, we did trial sequential analysis (TSA) for each pairwise meta-analytic comparison. We assessed the certainty of evidence using the GRADE approach.

Results: 70 RCTs were included (55,841 participants). Compared to LMWH, factor Xa inhibitors decreased risk of VTE (odds ratio[OR]:0.55,95%-confidence interval[CI]:0.44-0.68,high certainty), pentasaccharides (OR:0.61,95%-CI:0.36-1.02,moderate certainty) probably reduce VTE, and Factor IIa inhibitors (OR:0.75,95%-CI:0.40-1.42,low certainty) may reduce VTE. UFH (OR:1.31,95%-CI:0.91-1.89,moderate certainty) probably increases the risk of VTE, and warfarin (OR:1.75,95%-CI:1.25-2.45), aspirin (OR:1.91,95%-CI:1.22-2.99), placebo (OR:2.35,95%-CI:1.71-3.24), and usual care without thromboprophylaxis (OR:3.30,95%-CI:2.18-4.98) were associated with increased risk of VTE (high certainty). Factor Xa inhibitors may increase major bleeding (OR:1.06,95%-CI:0.81-1.39,low certainty). No medications were associated with increased mortality compared to LMWH. TSA for VTE prevention showed that between LMWH with factor Xa inhibitors, the required information size is attained, and the cumulative Z-curve crosses the boundary for benefit in favour of factor Xa inhibitors.

Conclusion(s): Post total hip or knee arthroplasty, factor Xa inhibitors are associated with reduced VTE, with a possible increase in bleeding and probably no impact on mortality compared to LMWH and aspirin.