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2014 Pennsylvania Chapter Eastern Region Abstract Winner

2014 Pennsylvania Chapter Eastern Region Abstract Winner

Residents Research
First Place

Efficacy of Apixaban for Prevention of Venous Thromboembolism in Patients Undergoing Arthroplasty: Systematic Review and Meta-analysis

Author: Sushil Ghimire, MBBS, Reading Hospital
Co-Authors: Madan Raj Aryal, MD, Paras Karmacharya, MBBS, Ranjan Pathak, MBBS, Dilli Ram Poudel, MBBS, Reading Health System; Anil Pandit, MBBS, Fadi Shamoun, MD, Raju Khanal, MBBS, Mayo Clinic

Background: Although the optimal regimen for thromboprophylaxis after knee replacement remains debated, low-molecular-weight heparins such as enoxaparin are currently the preferred agents. The ease of administration and lower bleeding risk make the newer oral anticoagulant, apixaban an attractive alternative. In this study, we sought to critically evaluate the efficacy and safety of apixaban after elective total knee and hip replacement.

Method: Studies were identified through electronic literature searches of MEDLINE, EMBASE,, SCOPUS and hand search for relevant articles from inception to February 2014. Phase III RCTs involving use of apixaban and enoxaparin for thromboprophylaxis in patients undergoing total knee or hip replacement were included. Study specific odd ratios were calculated and between-study heterogeneity was assessed using the I2 statistics.

Results: In three studies involving 11,659 patients, the risk of symptomatic deep vein thrombosis (DVT) (pooled OR 0.38, 95% CI, 0.16- 0.90, I2 = 0%, p = 0.03) and bleeding (pooled OR 0.87, 95% CI, 0.77-0.99, I2 = 0%, p = 0.03) were less in apixaban group compared with enoxaparin. However, it was interesting to note that on subgroup analysis, the risk of pulmonary embolism (PE) was higher with apixaban compared with enoxaparin when used for prophylaxis for knee replacement surgery (pooled OR 2.58, 95% CI 1.10 - 6.04, I2 = 0%, p = 0.03).

Conclusions: Apixaban, in comparison with enoxaparin, is associated with lower risk of symptomatic DVT and bleeding when used as thromboprophylaxis in patients undergoing knee and hip replacement surgery. However, it is associated with increased risk of PE as compared to enoxaparin in patients undergoing knee replacement. Until larger RCTs can address this concern, caution is required in the use of apixaban as thromboprophylaxis in this population.