Table 9U.S. guideline recommendations related to specific thromboprophylaxis strategies

ACCP 2012aAAOS 2011b
In patients undergoing THR or TKR, we recommend use of one of the following for minimum of 10–14 days rather than no antithrombotic prophylaxis: LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban low-dose unfractionated heparin (LDUH), adjusted-dose VKA, aspirin (all Grade 1B) or an intermittent pneumatic compression device (IPCD) (Grade 1C).We suggest the use of pharmacologic agents and/or mechanical compressive devices for the prevention of VTE in patients undergoing elective hip or knee arthroplasty, and who are not at elevated risk beyond that of the surgery itself for venous thromboembolism or bleeding.
Grade: Moderate
In patients undergoing THR or TKR, irrespective of the concomitant use of an IPCD or length of treatment, we suggest the use of LMWH in preference to the other agents we have recommended as alternatives: fondaparinux, apixaban, dabigatran, rivaroxaban low-dose unfractionated heparin (LDUH) (all Grade 1B), adjusted-dose VKA, aspirin (all Grade 2C).Current evidence is unclear about which prophylactic strategy is optimal or suboptimal. Therefore, we are unable to recommend for or against specific prophylactics in these patients.
Grade: Inconclusive
In patients undergoing major orthopedic surgery, we suggest using dual prophylaxis with an antithrombotic agent and an IPCD during the hospital stay (Grade 2C).In the absence of reliable evidence, patients who have had a previous VTE should receive pharmacologic prophylaxis and mechanical compressive devices.
Grade: Consensus
In patients undergoing major orthopedic surgery and increased risk of bleeding, we suggest using an IPCD or no prophylaxis rather than pharmacologic treatment (Grade 2C).In the absence of reliable evidence, patients with a known bleeding disorder and/or active liver disease should use mechanical compressive devices for preventing VTE.
Grade: Consensus
In patients undergoing major orthopedic surgery and who decline or are uncooperative with injections or an IPCD, we recommend using apixaban or dabigatran (alternatively, rivaroxaban or adjusted-dose VKA if apixaban or dabigatran are unavailable) rather than other forms of prophylaxis (Grade 1B).In the absence of reliable evidence about how long to employ these prophylactic strategies, it is the opinion of this work group that patients discuss the duration of prophylaxis with their treating physicians.
Grade: Consensus
a

ACCP evidence grading of evidence was as follows: grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs, while grade 2 suggestions imply that individual patient values may lead to different choices. Furthermore, level A indicates consistent results from RCTs or observational studies with very strong association and secure generalization (high), B indicates inconsistent results from RCTs or RCTs with methodological limitations (moderate), C indicates unbiased observational studies (low), and D indicates other observational studies (e.g. case series) (very low).

b

AAOS grading was as follows: strong when good-quality evidence, moderate when fair-quality evidence, weak when poor-quality evidence, inconclusive when insufficient or conflicting evidence, or consensus in the absence of reliable evidence.

Abbreviations: IPCD=intermittent pneumatic compression device; LDUH=low-dose unfractionated heparin; LMWH=low molecular weight heparin; THR=total hip replacement; TKR=total knee replacement; VKA=vitamin K antagonist; VTE=venous thromboembolism

From: SUMMARY AND DISCUSSION

Cover of Comparative Effectiveness of Newer Oral Anticoagulants and Standard Anticoagulant Regimens for Thromboprophylaxis in Patients Undergoing Total Hip or Knee Replacement
Comparative Effectiveness of Newer Oral Anticoagulants and Standard Anticoagulant Regimens for Thromboprophylaxis in Patients Undergoing Total Hip or Knee Replacement [Internet].
Adam SS, McDuffie JR, Lachiewicz PF, et al.
Washington (DC): Department of Veterans Affairs (US); 2012 Dec.

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