VTE events, either DVT or PE, are important complications in patients undergoing knee arthroplasty, as VTE is a major cause of death in hospitalized patients.
Patients undergoing total knee replacement surgery are at high risk of developing VTE in the postoperative period and after hospital discharge; and the health care costs of VTE are high, too. Hence, clinical guidelines recommend thromboprophylaxis for 10 to 35 days after TKA. Although widespread use of anticoagulants and improved surgical techniques have substantially reduced the thromboembolic event rates, VTE is still a dangerous complication and PE remains the main cause of death. Rivaroxaban (Xarelto) is an oral, direct antithrombin-independent factor Xa inhibitor, which restricts thrombin generation both in vivo and in vitro, and is a safe and potent new compound for antithrombotic prophylaxis after orthopedic surgery. Factor Xa is a coagulation factor leading to clot formation and thrombin generation. Rivaroxaban has predictable pharmacokinetics, a rapid onset of action and high oral bioavailability. Once-daily oral treatment of rivaroxaban could potentially improve adherence to extended-duration VTE treatment compared with enoxaparin in individuals with confirmed VTE or in administration of thromboprophylaxis. The oral administration of the treatment offers benefits on patient compliance and tolerability. Chen et al believed that rivaroxaban has the major advantages of no required laboratory monitoring and once-daily oral dosing, giving it the opportunity to replace current antithrombotics on the market today. Enoxaparin demonstrated budget overrun compared to rivaroxaban at TKA because of increasing thrombosis complications.[25,26] For VTE prophylaxis in patients undergoing total knee replacement in Canada, rivaroxaban is a cost-effective alternative to enoxaparin, providing more quality-of-life benefit at a lower cost. Ryttberg et al presented an economic model showing that rivaroxaban is a cost-effective alternative to 14 days of LMWH for VTE prophylaxis over a 5-year period in Sweden. Monreal et al suggested that the use of rivaroxaban could result in a mass of healthcare cost savings and improved quality of life after total knee replacement surgery. Similarly, in Duran et al's decision-analytic model, rivaroxaban reduced the payers’ costs of total therapy versus enoxaparin for the prevention of VTE in TKA patients in the US Loganathan et al suggested that if a hospital patient received enoxaparin treatment of after knee arthroplasty, he/she should receive rivaroxaban when discharged.
Bleeding events were the most commonly reported adverse events across TKA clinical trials, and compared with enoxaparin, the greater efficacy of rivaroxaban was achieved without a remarkable increase in the rate of major bleeding episodes. Ma G et al's research confirmed that direct Xa inhibitors were more effective for the prevention of VTE compared with enoxaparin after TKA, without increasing the risk of major bleeding. The dominant blood loss of the rivaroxaban group was lower than that of enoxaparin group after TKA (P = .003). In Francis et al's research, rivaroxaban was also superior to enoxaparin in the prevention of VTE and with no increase in bleeding complications. Adverse surgical events occurred at a similar rate in the enoxaparin group compared with the rivaroxaban group after total knee replacement (2.69% vs 2.26%, respectively). Similarly, there was also no significant difference in major bleeding between the 2 groups after TKA in our research.
In the coming years, the number of TKA surgeries was expected to increase significantly, and more effective and safer thromboprophylaxis was essential to mitigate the mortality and morbidity associated with VTE. Our study shows that rivaroxaban is more effective than enoxaparin and with no increase in major bleeding or all-cause death rates after TKA. Rivaroxaban is the primary drug of choice after total knee replacement surgery.
Conceived and designed the article: XBT, QX. Literature search and data extraction: HFH, XTY. Analyzed the data: HFH, SSL. Wrote the paper: HFH, XTY. All of the authors read and approved the final manuscript.
Quan Xie orcid: 0000-0002-2848-1745.
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