 These favourable results might help surgeons to resolve their clinical dilemma when considering anticoagulant prophylaxis for total knee replacement |
| Michael Rud Lassen et al. | An article published in The Lancet reports that apixaban is a more convenient and effective anticoagulant than enoxaparin. It is better at preventing venous thromboembolism after knee replacement surgery. Also, apixaban does not increase the risk of bleeding. This is an essential concern with anticoagulants since this can hinder recovery and predispose patients to infections that could damage the prosthesis.
Presently, the existing prophylactics such as heparins (like enoxaparin) or other drugs (such as fondaparinux) need regular injections. Furthermore, the use of warfarin has various disadvantages in routine practice, and mechanical methods are burdensome.
Michael Rud Lassen, Department of Orthopaedics, Horsholm Hospital, University of Copenhagen, Denmark, and colleagues investigated whether apixaban would be better than enoxaparin in keeping both thromboembolism and bleeding to a minimum. They undertook a randomised controlled phase 3 trial. Patients received either 2.5 mg apixaban twice daily or 40 mg enoxaparin once daily. The primary outcome was a composite of deep vein thrombosis, non-fatal pulmonary embolism and death from any cause.
A total of 147 patients (15% of 976) on apixaban and 243 (24% of 997) on enoxaparin had a primary outcome event. This showed a statistically significant difference. There was no noteworthy disparity between the groups in the bleeding during treatment.
The authors explain:
"2.5 mg apixaban twice daily, starting on the morning after total knee replacement, offers a convenient and more effective orally administered alternative to 40 mg per day enoxaparin, without increased bleeding."
They say in closing:
"These favourable results might help surgeons to resolve their clinical dilemma when considering anticoagulant prophylaxis for total knee replacement. Bleeding can delay recovery and can predispose to infections that endanger the prosthesis. The small but occasionally important increase in surgical bleeding that is attributed to enoxaparin can contribute to underuse of effective prophylaxis."
| We are potentially a step closer to the unmet need of oral antithrombotic therapy without need for monitoring |
| Dr Jawed Fareed and Dr Russell Hull | In an associated note, Dr Jawed Fareed, Department of Pathology, Loyola University Medical Center, Maywood, IL, USA, and Dr Russell Hull, University of Calgary, Calgary, Canada comment:
"We are potentially a step closer to the unmet need of oral antithrombotic therapy without need for monitoring."
They conclude:
"The ideal prophylactic drug would reduce the frequency of postoperative venous thromboembolism without causing bleeding and other complications in patients postoperatively. An ideal drug does not yet exist. The balance is fairly simple: a stronger anticoagulant effect is associated with fewer thrombotic events, but with a cost of increased occurrence of bleeding."
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