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2022/5/31

Apixaban or enoxaparin: Which is better for thromboprophylaxis after total hip and total knee arthroplasty in Indian patients? - Kunal - 202

…

https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.14959 1/14

British Journal of Clinical Pharmacology / Volume 88, Issue 2 / p. 830-835

SHORT COMMUNICATION



Full Access

Apixaban or enoxaparin: Which is better for thromboprophylaxis after total hip

and total knee arthroplasty in Indian patients?

First published: 29 June 2021

https://doi.org/10.1111/bcp.14959

The authors conrm that the PI for this paper is Kishor Kunal and that he had direct clinical responsibility for

patients.

Data available on request from the authors.

Abstract

Kishor Kunal, Sumit Banerjee, Pawan Kumar Garg, Abhay Elhence 

Both apixaban and enoxaparin are Food and Drug Administration-approved standard

therapy for prophylaxis of deep-vein thrombosis; however, the superiority of one over the

other is still controversial. With an objective to observe ecacy and safety outcomes of

apixaban and enoxaparin in patients undergoing total hip (THA) and knee (TKA)

arthroplasty, 96 patients undergoing THA/TKA (October 2018 to August 2019) were

randomly allocated into 2 groups; (n = 48) apixaban; and (n = 48) enoxaparin. Ecacy

outcomes and safety outcomes were recorded at 2 and 5 weeks post-TKA/THA. Follow-up

functional scoring was done at 6 months postoperatively. Apixaban and enoxaparin were

found to be equally ecacious in preventing venous thromboembolism; however, apixaban

had a better safety prole. The apixaban group had nonsignicant higher tendency for

wound discharge, atrial brillation and transient ischaemic attack. Enoxaparin had

nonsignicant greater tendency for bleeding, wound dehiscence and pulmonary

complications. Apixaban is a safe alternative to conventionally used enoxaparin for

chemoprophylaxis in patients undergoing THA or TKA.

What is already known about this subject

Approximately 40% patients undergoing hip and knee arthroplasty develop

asymptomatic venous thromboembolism (VTE) within few days of surgery.

2022/5/31

Apixaban or enoxaparin: Which is better for thromboprophylaxis after total hip and total knee arthroplasty in Indian patients? - Kunal - 202

…

https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.14959 2/14

Symptomatic VTE ranges from 1 to 5% in the above group compared to 0.1–0.2%

in the general population.

Both apixaban and enoxaparin are used as standard therapies for prophylaxis of

deep-vein thrombosis and have been approved by the Food and Drug

Administration. Some studies have shown no improved benet of apixaban over

enoxaparin, while others have shown apixaban is more eective in preventing

major thromboembolic episode without increased risk of bleeding.

There is no signicant dierence in functional outcomes with or without

thromboprophylaxis.

What this study adds

First observational study in Indian population to compare safety and ecacy of 2

commonly used drugs for thromboprophylaxis in patients undergoing total hip

and knee arthroplasty.

First observational study to compare the functional outcomes between apixaban

and enoxaparin in patients undergoing total hip and knee arthroplasty in

literature.

First study to compare 6-month follow-up of safety and ecacy outcomes of

apixaban and enoxaparin in patients receiving the same for chemoprophylaxis of

VTE following total hip and knee arthroplasty in literature.

Considering the similar (nonsignicant numerically better) safety and ecacy

proles of oral apixaban in Indian patients with convincing results in European

population, it can be recommended for thromboprophylaxis in Indian setting,

over traditionally prescribed parenteral enoxaparin, which can be costly and have

local complications. Also, this study can form the basis for further research in an

Indian setting, given the similarity of patient proles and medical infrastructure

and guidelines.

1 INTRODUCTION

Approximately 40% patients undergoing hip and knee arthroplasty develop asymptomatic

venous thromboembolism (VTE) within few days of surgery. Symptomatic VTE ranges from 1

to 5% in the above group compared to 0.1 to 0.2% in the general population. Falck-Ytter et al.

reported that risk of symptomatic VTE in patients using pharmacological prophylaxis is 1.2%

(0.8% deep-vein thrombosis [DVT] and 0.4% pulmonary embolism [PE]) within 14 days following

1, 2

3-5

2022/5/31

Apixaban or enoxaparin: Which is better for thromboprophylaxis after total hip and total knee arthroplasty in Indian patients? - Kunal - 202

…

https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.14959 3/14

surgery. The overall reduction in symptomatic and asymptomatic VTE following

pharmacological thromboprophylaxis has been observed at 50–70%.

7, 8

2 METHODOLOGY

The study design was prospective observational study- Level 2b evidence. It included all the

patients meeting inclusion criteria (Table 1) between 1 October 2018 and 31 August 2019 who

underwent elective total hip (THA) and knee (TKA) arthroplasty at our institution, unless the

patient met an exclusion criterion (Table 1).

TABLE 1. Inclusion–exclusion criteria and safety and ecacy outcome

Enoxaparin 40 mg (0.4 mL) was administered subcutaneously every 24 hours and apixaban 2.5

mg was administered orally in tablet form every 12 hours for 2 weeks in TKA and 5 weeks in

Inclusion

criteria

Patients were considered eligible if they were undergoing either elective unilateral or simultaneous

bilateral total knee arthroplasty and total hip arthroplasty and were willing to undergo Doppler studies.

Informed written consent was obtained from all patients undergoing the above-mentioned procedures

Exclusion

criteria

• hereditary (rst degree) or acquired bleeding or coagulation disorder.

• known or suspected history of heparin-induced thrombocytopenia.

• need for ongoing treatment with a parenteral or oral anticoagulant (e.g., subjects with mechanical

valves, warfarin-eligible atrial brillation).

• known coagulopathy.

• active bleeding.

• active hepatobiliary disease.

• any condition, in the opinion of the investigator, for which surgery or administration of an

anticoagulant was contraindicated.

• hypersensitivity to unfractionated heparin, low molecular weight heparin, porcine products, or

iodinated contrast medium.

• pre-operative deep vein thrombosis detected in Doppler ultrasound and patients with previous

known/documented history of thrombogenic events such as deep-vein thrombosis (DVT) and pulmonary

embolism.

Ecacy • symptomatic DVT

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