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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
Method: Studies were identified through
electronic literature searches of MEDLINE, EMBASE,
clinicaltrial.gov, 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.