Abstract
BackgroundTrauma patients are at a significant risk of venous thromboembolism (VTE), with lower extremity fractures (LEF) being independent risk factors. Use of direct oral anticoagusants (DOACs) for VTE prophylaxis is effective in elective orthopedic surgery, but currently not approved for trauma patients. The primary objective of this study was to compare the effectiveness and safety of thromboprophylaxis of DOACs with low-molecular-weight heparin (LMWH) in trauma patients sustaining LEF. Materials and methodsWe included adult trauma patients admitted to trauma quality improvement program participating trauma centers (between 2013 and 2016), who sustained LEF and were started on DOACs or LMWH for thromboprophylaxis after admission. Propensity score matching was performed to compare symptomatic VTE and bleeding control interventions between the groups. ResultsOf 1,009,922 patients in trauma quality improvement program, 167,640 met inclusion criteria (165,009 received LMWH and 2631 received DOACs). After propensity score matching, 2280 predominantly elderly (median age: 67 y) isolated femur fracture patients (median ISS: 10) were included in each group (4560 patients in total). Symptomatic VTE occurred in 1.4% of patients in both matched groups (P = 0.992). Bleeding control interventions occurred less often in the DOAC group, albeit statistically insignificant (5.8% versus 6.0%, P = 0.772). ConclusionsThis study found similar rates of VTE and bleeding control measures for thromboprophylaxis with DOACs or LMWH in matched trauma patients with LEF. Further prospective research is warranted to consolidate the safety of DOAC thromboprophylaxis in trauma patients with LEF. Favorable oral administration and likely increased adherence could benefit this high-risk population.
Highlights
Trauma patients are at a significant risk of venous thromboembolism (VTE), with lower extremity fractures (LEF) being independent risk factors
Our results from a propensity matched, nationwide cohort study indicate that the odds of developing in-hospital VTE were similar for trauma patients with LEF using direct oral anticoagusants (DOACs) as thromboprophylaxis compared with those using lowmolecular-weight heparin (LMWH)
The results found in this study are in line with the results from randomized trials comparing DOACs and LMWH for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA), such as the RE-NOVATE, RE-MODEL, RECORD, and ADVANCE trials.[2,21,22,23,24,25,26]
Summary
Trauma patients are at a significant risk of venous thromboembolism (VTE), with lower extremity fractures (LEF) being independent risk factors. Several randomized controlled trials have studied the effectiveness and safety of direct oral anticoagulants (DOACs) for thromboprophylaxis in elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).[1,2,3,4] A meta-analysis of 16 randomized trials found DOACs, that is dabigatran (DTI), rivaroxaban, and apixaban, to be equivalent or superior to low-molecular-weight heparin (LMWH) in terms of venous thromboembolism (VTE) prevention.[5] Safety, measured through the incidence of major bleeding, was equivalent for DTI, inferior for rivaroxaban, and superior for apixaban when compared with enoxaparin for THA and TKA Following these positive results on the effectiveness and safety of DOACs, their use for thromboprophylaxis was approved for patients undergoing elective THA and/or TKA in over 100 countries.[6,7]. When prescribing PTP, the choice of prophylactic medication is still subject to discourse, with LMWH being the current standard.[15,16,17]
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