Direct-acting oral anticoagulants for VTE prophylaxis
Direct-acting oral anticoagulants (DOACs) (eg apixaban, dabigatran, rivaroxaban) are effective for venous thromboembolism (VTE) (ie deep vein thrombosis [DVT] or pulmonary embolism [PE]) prophylaxis following total hip or knee replacement surgery.
For DOAC indications and duration for surgical patients, see VTE prophylaxis for surgical patients in hospital. For nonsurgical patients, low molecular weight heparin (LMWH) is recommended over DOACs, because DOACs have an increased risk of major bleeding in this setting Schunemann, 2018.
DOAC dosage regimens for VTE prophylaxis are Clinical Excellence Commission (CEC), Updated 2017:
1apixaban (CrCl 25 mL/min or more) 2.5 mg orally, twice daily apixaban apixaban apixaban
OR
1dabigatran dabigatran dabigatran dabigatran
CrCl more than 50 mL/min: 110 mg orally within 1 to 4 hours of surgery completion, then increase from the next day to 220 mg once daily1
CrCl 30 to 50 mL/min: 75 mg orally within 1 to 4 hours of surgery completion, then increase from the next day to 150 mg once daily2
OR
1rivaroxaban (CrCl 15 mL/min or more) 10 mg orally, once daily. rivaroxaban rivaroxaban rivaroxaban
Do not use apixaban if calculated creatinine clearance (CrCl) is less than 25 mL/min, dabigatran if CrCl is less than 30 mL/min, or rivaroxaban if CrCl is less than 15 mL/min. At the time of writing, rivaroxaban has been studied in a limited number of VTE patients with a CrCl of 15 to 29 mL/min; only consider its use in these patients under specialist adviceAgeno, 2016Prins, 2014.
If using a DOAC in a patient with obesity, standard doses of rivaroxaban or apixaban are appropriate, regardless of BMI and weight; data are lacking on the use of dabigatran. DOACs should not be used for initial VTE prophylaxis after bariatric surgery because absorption is decreased in this setting; parenteral anticoagulants are recommended as initial therapyMartin, 2021. See also Direct-acting oral anticoagulants (DOACs) for VTE prophylaxis and treatment in patients with obesity.