A 45-year-old male patient tore his right anterior cruciate ligament playing soccer with his son. He underwent an uncomplicated ligament repair of his right knee. His medications included a daily multivitamin and 25 mg of hydrochlorothiazide daily. Postoperatively, his temperature was 97.5 degrees F, his blood pressure was 128/75 mmHg, his heart rate was 62 bpm, and he had an oxygen saturation of 97% on room air. Per the surgeon, he will be unable to bear any weight on his right leg for the next 3 weeks.
What is the best medical treatment to prevent deep vein thrombosis (DVT) on discharge?
Show Answer
The correct answer is: C. Rivaroxaban 10 mg daily for the next 30 days
Nonmajor lower limb surgery (knee arthroscopy, ankle fractures, tibial fractures, and the like) leads to a period of reduced mobility and increases the risk of venous thromboembolism (VTE) to approximately 3%.1 European guidelines therefore recommend considering the use of low molecular weight heparin in patients with one or more risk factors for VTE.2 The factor Xa inhibitor (rivaroxaban) is associated with lower DVT risk and mortality in major orthopedic surgery (total hip and knee replacement) compared with enoxaparin.3 In the PRONOMOS (Prophylaxis in Non Major Orthopaedic Surgery) study, patients undergoing nonmajor lower limb orthopedic surgery were randomized to receive rivaroxaban (10 mg daily) or subcutaneous enoxaparin (40 mg daily) for the duration of their immobilization period (mean 28.6 ± 14.3 days). Rivaroxaban was superior to enoxaparin in preventing VTE (0.2% vs. 1.1%, relative risk of 0.25; 95% confidence interval, 0.09-0.75) with similar clinically relevant nonmajor and major bleeding (1.1% vs. 1.0%, relative risk 1.04; 95% confidence interval, 0.55-2.00).4 The VTE prophylaxis dose is 10 mg daily as opposed to 20 mg daily for stroke prevention for non-valvular atrial fibrillation.5
References
Chapelle C, Rosencher N, Zufferey PJ, et al. Prevention of Venous Thromboembolic Events With Low-Molecular-Weight Heparin in the Non-Major Orthopaedic Setting: Meta-Analysis of Randomized Controlled Trials. Arthroscopy 2014;30:987-96.
Gee E. The National VTE Exemplar Centres Network Response to Implementation of Updated NICE Guidance: Venous Thromboembolism in Over 16s: Reducing the Risk of Hospital-Acquired Deep Vein Thrombosis or Pulmonary Embolism (NG89). Br J Haematol 2019;186:792-3.
Turpie AGG, Lassen MR, Eriksson BI, et al. Rivaroxaban for the Prevention of Venous Thromboembolism After Hip or Knee Arthroplasty. Pooled Analysis of Four Studies. Thromb Haemost 2011;105:444-53.
Samama CM, Laporte S, Rosencher N, et al. Rivaroxaban or Enoxaparin in Nonmajor Orthopedic Surgery. N Engl J Med 2020;382:1916-25.
Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban Versus Warfarin in Nonvalvular Atrial Fibrillation. N Engl J Med 2011;365:883-91.
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