Blood thinning medications anticoagulants often are given to patients just before or after a total joint replacement to reduce the risk of blood clots following surgery.
Warfarin is taken in the form of a pill, but the patient is required to undergo blood tests and monitoring while taking it, whereas LMWH, administered via an injection, requires no monitoring or blood tests, according to the study. Previous, single-site studies have suggested that there may be an association between preventive anticoagulant use and post-surgery infections or other problems, but this is the first multi-site study addressing the issue.
Bhattacharyya and colleagues in the NIAMS Clinical Trials and Outcomes Branch collaborated with researchers from the University of Massachusetts to examine data in the Global Orthopedic Registry GLORY , an international database of surgeon-submitted patient information, including outcomes and which type of blood clot prevention the patient was prescribed.
The researchers looked at a subset of records from 3, patients who had undergone a hip or knee replacement surgery in the United States. Is a common pain reliever safe during pregnancy? Can vaping help you quit smoking? On call: Anticoagulation following hip replacement March 9, Research health conditions Check your symptoms Prepare for a doctor's visit or test Find the best treatments and procedures for you Explore options for better nutrition and exercise Learn more about the many benefits and features of joining Harvard Health Online ».
Sign Me Up. Print This Page Click to Print. Free Healthbeat Signup Get the latest in health news delivered to your inbox! Sign Up. Close Thanks for visiting. The Best Diets for Cognitive Fitness , is yours absolutely FREE when you sign up to receive Health Alerts from Harvard Medical School Sign up to get tips for living a healthy lifestyle, with ways to fight inflammation and improve cognitive health , plus the latest advances in preventative medicine, diet and exercise , pain relief, blood pressure and cholesterol management, and more.
I want to get healthier. In the Pulmonary Embolism Prevention PEP trial, 13, patients who underwent surgery for hip fracture were randomized to receive either aspirin mg daily or placebo, starting preoperatively and continuing for 35 days postoperatively. The PEP trial results come with a caveat, however, as a subgroup analysis of patients who also received low-molecular-weight heparin showed no statistically significant difference between aspirin and placebo in the rate of symptomatic VTE.
Trials of thromboprophylaxis using the vitamin K antagonist warfarin are limited in hip fracture patients. The largest was a prospective randomized controlled trial of hip fracture patients who received aspirin mg twice daily, or warfarin titrated to an international normalized tatio INR goal of 2. There were no significant differences with respect to adverse bleeding outcomes among the three groups. Only a few trials have compared the effectiveness of low-dose unfractionated heparin with other agents for VTE prophylaxis in hip fracture patients.
One prospective, double-blind, randomized controlled trial compared 90 hip fracture patients who received either low-dose unfractionated heparin 5, U every 8 hours or the lowmolecular-weight heparin dalteparin 5, U daily. Both of these findings were statistically significant. No significant difference was observed with respect to bleeding complications. A study of enoxaparin vs dalteparin in hip fracture patients 23 found no significant difference in the frequency of DVT or bleeding complications.
Fondaparinux 2. If the first dose of anticoagulant is given immediately on presentation, how does this influence the timing of surgery? This largely depends on which pharmacologic agent is used. An agent with a short halflife, such as low-dose unfractionated heparin 5, U, would allow hip fracture surgery to be performed safely under neuroaxial blockade spinal or epidural anesthesia after 6 to 8 hours without increasing the risk of epidural hematoma.
If a prophylactic dose of a low-molecular-weight heparin such as dalteparin or enoxaparin is used, the surgery could be performed safely as early as 12 hours after the dose is given. With fondaparinux, however, it may not be safe to proceed under neuroaxial blockade, even at 24 hours, as it has a half-life of 18 hours. We have neither the data nor a consensus recommendation to guide the preoperative timing of fondaparinux if neuroaxial blockade is planned. Exactly when to restart anticoagulation after surgery is an important issue as well.
And once the catheter is pulled, one must wait 2 hours to give another dose of heparin. Before randomization, all patients had received fondaparinux for 6 to 8 days postoperatively. Using bilateral venography, the total incidence of VTE was This study supports extended prophylaxis with fondaparinux for a total of 4 weeks after hip fracture surgery. The main outcomes of interest were symptomatic showing symptoms VTE, including DVT and PE, and bleeding major, clinically relevant non-major and minor bleeding.
Six studies compared heparin with placebo, one compared the vitamin K antagonist VKA warfarin with placebo, two compared DOAC with placebo, one compared VKA with heparin, five compared DOAC with heparin and one study compared using a variety of anticoagulant treatments with placebo. Only three trials included participants undergoing knee replacement and no studies included participants undergoing hip fracture repair.
For the comparison heparin versus placebo six studies no differences were found between the study arms for symptomatic VTE, symptomatic DVT, symptomatic PE and major bleeding.
Minor bleeding was increased in the heparin group. Clinically relevant non-major bleeding was not reported. The comparison VKA versus placebo one study and the comparison placebo with anticoagulants chosen at the discretion of the investigators one study showed no differences between the study arms for symptomatic VTE, symptomatic DVT, symptomatic PE and major bleeding. Clinically relevant non-major bleeding and minor bleeding were not reported.
Overall, the included studies were of good methodological quality, with the majority of studies having little risk of bias due to study design and reporting.
The majority of concerns came from lack of reporting of specific details. The quality of the evidence was generally moderate, either because only one study was included in a comparison, because of few events or because there were a lot of differences between the findings of the studies meaning that the data were difficult to interpret.
Further studies are needed to better understand the relationship between VTE and extended-duration oral anticoagulants for knee replacement and hip fracture repair as well as outcomes such as DVT below the knee and above the knee, reoperation, wound infection and healing. Moderate quality evidence suggests extended-duration anticoagulants to prevent VTE should be considered for people undergoing hip replacement surgery, although the benefit should be weighed against the increased risk of minor bleeding.
0コメント