Related Experiment Video
Updated: Dec 18, 2025
The Transition to an Anterior-Based Muscle Sparing Approach Improves Early Postoperative Function but is Associated with a Learning Curve
Published on: September 7, 2022
Temporal trends in pharmacologic prophylaxis for venous thromboembolism after hip and knee replacement in older
Darae Ko1, Alok Kapoor2, Adam J Rose3
1Section of Cardiovascular Medicine, Boston University Medical Center, Boston, MA, USA.
Insights
Direct oral anticoagulants (DOACs) are increasingly used for venous thromboembolism (VTE) prophylaxis after hip and knee replacement surgery. Overall adverse event risks remain low across all prophylaxis methods.
Area of Science:
- Orthopedic Surgery
- Pharmacology
- Public Health
Background:
- Venous thromboembolism (VTE) prophylaxis is standard after total hip (THR) and knee replacement (TKR).
- The impact of direct oral anticoagulants (DOACs) and aspirin guidelines on VTE prophylaxis practices is not well understood.
- Risks of adverse events associated with different VTE prophylaxis strategies require investigation.
Purpose of the Study:
- To examine trends in VTE prophylaxis prescribing patterns following THR and TKR.
- To assess the risks of adverse events associated with different prophylaxis agents.
- To analyze practice patterns in relation to DOAC availability and aspirin guideline endorsement.
Main Methods:
- Retrospective analysis of 10,503 in-hospital and 5722 discharge patients undergoing THR/TKR (age ≥ 65).
- Data sourced from the Institute for Health Metrics database (2011-2013).
- Medications analyzed: fondaparinux, DOACs, low molecular weight heparin (LMWH), heparin, warfarin, and aspirin. Outcomes (VTE, hemorrhage, cardiovascular events, death) validated by physician review.
Main Results:
- Pharmacologic prophylaxis was nearly universal (93% in-hospital, 99% at discharge).
- DOAC use significantly increased, becoming the choice for ~25% (in-hospital) and ~33% (discharge) of patients.
- Aspirin was used as sole discharge prophylaxis in 17-19% of THR/TKR patients; warfarin remained preferred for patients ≥ 80 years.
- Overall adverse event risk was low (<1%) for both in-hospital and discharge periods.
Conclusions:
- DOACs have become a major VTE prophylaxis agent post-THR/TKR, alongside aspirin and warfarin.
- Prescribing patterns have shifted following DOAC approval and updated guidelines.
- The low incidence of adverse events limits comparative analysis of different prophylaxis regimens.
Abstract:
Trends in prescription for venous thromboembolism (VTE) prophylaxis following total hip (THR) and knee replacement (TKR) since the approval of direct oral anticoagulants (DOACs) and the 2012 guideline endorsement of aspirin are unknown, as are the risks of adverse events. We examined practice patterns in the prescription of prophylaxis agents and the risk of adverse events during the in-hospital period (the 'in-hospital sample') and 90 days following discharge (the 'discharge sample') among adults aged ⩾ 65 undergoing THR and TKR in community hospitals in the Institute for Health Metrics database over a 30-month period during 2011 to 2013. Eligible medications included fondaparinux, DOACs, low molecular weight heparin (LMWH), other heparin products, warfarin, and aspirin. Outcomes were validated by physician review of source documents: VTE, major hemorrhage, cardiovascular events, and death. The in-hospital and the discharge samples included 10,503 and 5722 adults from 65 hospitals nationwide, respectively (mean age 73, 74 years; 61%, 63% women). Pharmacologic prophylaxis was near universal during the in-hospital period (93%) and at discharge (99%). DOAC use increased substantially and was the prophylaxis of choice for nearly a quarter (in-hospital) and a third (discharge) of the patients. Aspirin was the sole discharge prophylactic agent for 17% and 19% of patients undergoing THR and TKR, respectively. Warfarin remained the prophylaxis agent of choice for patients aged 80 years and older. The overall risk of adverse events was low, at less than 1% for both the in-hospital and discharge outcomes. The low number of adverse events precluded statistical comparison of prophylaxis regimens.
Related Concept Videos
01:29Venous Thrombosis III: Interprofessional Care
01:30Venous Thrombosis IV: Nursing Management
01:27Pharmacodynamics in Geriatric Patients: Effects of Age
01:00Pharmacokinetics in Geriatric Patients: Effect of Age on Drug Distribution
01:18Pharmacokinetics in Geriatric Patients: Effect of Age on Drug Excretion
01:18Anticoagulant Drugs: Vitamin K Antagonists and Direct Oral Anticoagulants
Warfarin, a prominent vitamin K antagonist family member, exerts its effect by inhibiting the enzyme VKORC1 (vitamin K epoxide reductase complex 1). By hindering this enzyme, warfarin...