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Current Concepts in DVT Prophylaxis in Total Joint Arthroplasty

Current Concepts in DVT Prophylaxis in Total Joint Arthroplasty. Shane Woolever D.O. Agenda. Coumadin LMWH Coumadin v. LMWH Hirudin Hirudin V. LMWH. Coumadin (warfarin). Inhibits Metabolism of Vitamin K Long onset of action (24-72hrs) Long half life Inexpensive

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Current Concepts in DVT Prophylaxis in Total Joint Arthroplasty

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  1. Current Concepts in DVT Prophylaxis in Total Joint Arthroplasty Shane Woolever D.O.

  2. Agenda • Coumadin • LMWH • Coumadin v. LMWH • Hirudin • Hirudin V. LMWH

  3. Coumadin (warfarin) • Inhibits Metabolism of Vitamin K • Long onset of action (24-72hrs) • Long half life • Inexpensive • Requires routine lab draws • Efficacy and safety well established

  4. Low Molecular Weight Heparins • Effect coagulation cascade at inhibitory level • Requires S/C injections • Relatively expensive • Safe ?

  5. LMWH • Fragmin(dalteparin sodium) • Pharmacia & Upjohn • Lovenox(enoxaparin sodium) • Rhone-Poulenc Rorer • Normiflo(ardeparin sodium) • Wyeth • Orgaran(danaparoid sodium) • Organon

  6. FDA ADVISORY15 December 1997 • As of Nov., 1997 > 30 safety reports involving enoxaparin used concomitantly with spinal anesthesia • neurologic injury - paralysis • 75% were women > 65yrs LMWH and Spinal/Epidural Anesthesia

  7. DVT 26% (49 of 190) Major bleeding complications = LMWH blood loss intra-op = LMWH DVT 15%(28 of 192) > bleeding comps involving wound site > post-op blood transfusions Coumadin v. LMWHJBJS, Nov. 9.,1997,vol 79-A, p.1365-1371. Coumadin LMWH

  8. Cost AnalysisArch Int Med Feb., 1997 • LMWH > cost effectiveness • Warfarin $2.01/day + INR cost • LMWH $15/day • Canadian Study: prices may vary LMWH v.Warfarin

  9. Cost Analysis (GENESYS) LMWH v.Warfarin • LMWH(enoxaparin) $12.89/ dose x2 • Warfarin(2mg) $0.03 • INR $15.00 • LMWH $25.78/day v. Warfarin $15.03/day

  10. LMWH Prophylaxis(post-discharge) • Decrease risk of PE and DVT given 30 days post-discharge • DVT - LMWH v. placebo (6.1% v. 21.4%) • PE - LMWH v. placebo ( #2 v. none) • LMWH (n=131) • placebo (n=131) Orthopedics, Feb. 20, 1997, sup 22-25.

  11. HIRUDIN • Leach Enzyme • Recombinant DNA multiplication • Appears safe • Possibly better than LMWH • Direct thrombin inhibitor

  12. LMWH v. HIRUDINNEJM ,Nov.6, 1997, vol. 337,p.1329-35 • Double bind study @ 31 centers 10 countries (1587 patients) • Safety profiles equal • DVT (overall) DVT(proximal) LMWH 25.5% LMWH 7.5% Hirudin 18.5% Hirudin 4.5% • Overall reduction in risk 28% (P=0.001)

  13. Adjuncts • SCD’s • Early Ambulation • Electrical stimulation- induced contraction (experimental)

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