Marc Carrier: Aspirin vs Anticoagulants for VTE Prevention After Joint Replacement
Marc Carrier, Advancing Catheter-Related Thrombosis Prevention Through Factor XI Inhibition, shared a post on LinkedIn about recent articles, adding:
“Aspirin after total hip or knee arthroplasty: How do we reconcile EPCAT III and PEPPER?
Two trials in NEJM Group offer different conclusions, but they asked different questions.
EPCAT III compared aspirin 81 mg daily with rivaroxaban for the first 5 postoperative days, followed by aspirin.
Symptomatic proximal DVT or PE occurred in 0.48 percent versus 0.45 percent, meeting the prespecified noninferiority criterion.
No significant difference in clinically relevant bleeding was demonstrated.
PEPPER compared 30 days of aspirin 81 mg twice daily, rivaroxaban, or warfarin.
Aspirin did not meet the noninferiority criterion for death or symptomatic VTE at 6 months. For aspirin versus rivaroxaban, the estimated difference was 0.30 percentage points (95 percent CI, 0.20 to 0.81).
Interpretation:
- The comparator matters. EPCAT III informs whether an initial 5 day course of rivaroxaban adds benefit before aspirin, it does not establish equivalence between aspirin and a full anticoagulant course.
- The outcomes and follow up differ: proximal DVT/PE at 90 days versus death or symptomatic VTE at 6 months. Event rates cannot be compared directly.
- Failure to demonstrate noninferiority is not proof of inferiority. PEPPER leaves uncertainty about both the efficacy trade off with aspirin and the safety trade off with anticoagulation.
In practice, I would discuss aspirin as an option for selected elective arthroplasty patients, while favouring anticoagulant prophylaxis when VTE risk is higher and bleeding risk permits.”
Title 1: Rivaroxaban Then Aspirin vs. Aspirin Alone after Total Hip or Knee Arthroplasty
Authors: Sudeep Shivakumar, Davide Matino, David Zukor, Susan R. Kahn, George Vincent, Raman Mundi, Pascal-Andre Vendittoli, Mohammad Refaei, Eric Bohm, Michael Tanzer, Stéphane Pelet, Glen Richardson, James Powell, Rick Ikesaka, James Douketis, Sarah Ward, Paul Kim, Stephen Mann, Susan Pleasance, Jocelyn Cormier, Pantelis Andreou, Kara Matheson, Chris Theriault, Carol West, David Anderson, Peter L. Gross
Read Full Article on The New England Journal of Medicine.
Title 2: Prevention of Venous Thromboembolism after Total Hip or Knee Replacement
Authors: Vincent D. Pellegrini, Carol A. Lambourne, Laurence S. Magder, Patricia D. Franklin, Jay S. Magaziner, Brook I. Martin, Richard Iorio, Kevin L. Garvin, Michael A. Mont, Wayne E. Moschetti, Antonia F. Chen, David Warwick, C. McCollister Evarts, Adina Harri, Laura M. Kernan, Samuel Z. Goldhaber, William J. Maloney, Zeke J. Walton, James A. Browne, Harry A. Demos, James I. Huddleston, Stephen L. Kates, Peter J. Brooks, Navin D. Fernando, Brock A. Lindsey, Matthew J. Dietz, James Nace, Ronald E. Delanois, Michael S. Kain, Mark J. Spangehl, Brent A. Lanting, Eric M. Cohen, Lisa K. Moores, William L. Healy, Charles W. Francis
Read Full Article on The New England Journal of Medicine.
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