A 72-year-old man with a history of obesity, stable coronary artery disease, and known Factor V Leiden mutation presents for pre-operative cardiovascular assessment prior to a planned right hip arthroplasty surgery. His current medications include aspirin 81mg daily, metoprolol 50mg twice a day, atorvastatin 40mg daily, and lisinopril 5mg daily. He has no known prior history of venous thromboembolism (VTE) or cancer. His most recent renal function and liver function laboratory values were normal.
Which of the following regimens would be appropriate for prevention of VTE following his orthopedic surgery?
The correct answer is: E. Rivaroxaban 10mg daily for 35 days.
Most patients undergoing hip replacement surgery should receive thromboprophylaxis with either aspirin or an anticoagulant medication, according to recent guideline documents. Guidelines suggest that direct oral anticoagulants (DOACs) be used preferentially over low-molecular-weight heparin and warfarin when anticoagulation therapy is given. Large registry-based studies and meta-analyses suggest that aspirin is similarly effective to anticoagulation for most patients but reduces the risk of major bleeding. For patients at high risk of venous thromboembolism, a 35-day course of anticoagulation is appropriate.
Warfarin 5mg twice a day for 35 days is incorrect since warfarin is dosed once per day (not twice a day) and DOAC therapy is preferred over warfarin.
Enoxaparin 40mg three times a day for 10 days is incorrect since enoxaparin is dosed only once a day for venous thromboembolism prophylaxis and the recommended length of treatment is 35 days for hip replacement surgery.
Dabigatran 75mg daily for 14 days is incorrect since the dose for venous thromboembolism prophylaxis after hip replacement surgery is 110mg orally for one day then 220mg daily.
Aspirin 325mg twice a day for 60 days is incorrect since the typical dose of aspirin used for venous thromboembolism prophylaxis after hip replacement surgery is 81mg daily (not 325mg twice a day) and the duration is only for 35 days.
Dr. Stanislav Henkin, MD, FACC served as a peer reviewer for this patient case.
Supported by an educational grant from Janssen Pharmaceuticals, Inc., administered by Janssen Scientific Affairs, LLC.
To visit the Online Course page for the Practical Management of VTE: Simplifying Anticoagulation Strategies Grant, click here!
Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med 2014;9:579-85.
Muscatelli SR, Zheng H, Hughes RE, Cowen ME, Hallstrom BR. Non-Inferiority of Aspirin for Venous Thromboembolism Prophylaxis After Hip Arthroplasty in a Statewide Registry. J Arthroplasty 2021;36(6):2068-2075.e2.
Anderson DR, Morgano GP, Bennett C, et al. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv 2019;3:3898-944.