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Rivaroxaban versus enoxaparin after total knee arthroplasty

2009; Elsevier BV; Volume: 374; Issue: 9691 Linguagem: Inglês

10.1016/s0140-6736(09)61551-8

1474-547X

Umile Giuseppe Longo, Nicola Maffulli, Vincenzo Denaro,

Heparin-Induced Thrombocytopenia and Thrombosis

Alexander Turpie and colleagues1Turpie AG Lassen MR Davidson BL et al.for the RECORD4 InvestigatorsRivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty (RECORD4): a randomised trial.Lancet. 2009; 373: 1673-1680Summary Full Text Full Text PDF PubMed Scopus (875) Google Scholar show that rivaroxaban, an orally active, highly selective, direct inhibitor of activated factor X, given at a fixed dose of 10 mg daily, holds the promise of greatly simplifying thromboprophylaxis in patients undergoing total knee arthroplasty. However, we feel that some concerns2Lotke PA Rivaroxaban for thromboprophylaxis.N Engl J Med. 2008; 359: 2174Crossref PubMed Google Scholar, 3Lippi G Franchini M Targher G Rivaroxaban for thromboprophylaxis.N Engl J Med. 2008; 359: 2174Crossref PubMed Google Scholar, 4ten Cate H Hamulyak K Rivaroxaban for thromboprophylaxis.N Engl J Med. 2008; 359: 2174Crossref PubMed Scopus (4) Google Scholar remain unresolved. The risk of venous thromboembolism after orthopaedic surgery needs to be balanced against the unstudied potential complications of anticoagulant drugs. Most studies of anticoagulant therapy investigate the efficacy and safety of a drug to prevent venous thromboembolism, but they do not take into account many surgical outcomes which normally guide an orthopaedic surgeon's choice of anticoagulant (ie, wound healing, drainage, infection, range of motion, and chronic pain).2Lotke PA Rivaroxaban for thromboprophylaxis.N Engl J Med. 2008; 359: 2174Crossref PubMed Google Scholar To date, there is no specific antidote to reverse the effects of activated factor X inhibitors.3Lippi G Franchini M Targher G Rivaroxaban for thromboprophylaxis.N Engl J Med. 2008; 359: 2174Crossref PubMed Google Scholar The unpredictable off-target effects of selective anticoagulants should also be considered, since proteases such as thrombin also have a role in disorders such as atherosclerosis and cancer. Therefore long-term clinical monitoring of their effects is required.4ten Cate H Hamulyak K Rivaroxaban for thromboprophylaxis.N Engl J Med. 2008; 359: 2174Crossref PubMed Scopus (4) Google Scholar Until all these points are answered, we suggest that the non-selective administration of rivaroxaban instead of enoxaparin for thromboprophylaxis in all patients undergoing total knee arthroplasty remains questionable. We declare that we have no conflicts of interest. Rivaroxaban versus enoxaparin after total knee arthroplasty – Authors' replyThe RECORD programme compared rivaroxaban 10 mg once daily with either the EU or North American approved regimens of enoxaparin (40 mg once daily or 30 mg twice daily). As Nina Raju and colleagues note, factors such as pharmacological target and differences in dose and frequency, as well as timing of initial postoperative drug administration, can affect the safety or efficacy of anticoagulants. However, RECORD4 and the RECORD programme as a whole were not designed to compare different enoxaparin regimens or to provide indirect comparisons on the efficacy of new anticoagulants. Full-Text PDF