Aspirin for DVT prophylaxis in orthopedic patients

[tweaked17]

In the past few months, I've observed a shift in post-operative DVT prophylaxis for orthopedic patients from LMWH to ASA. Nearly 100% at my institution with regard to TKA/THAs.

I know that ASA was included as an option for DVT prophylaxis in this patient population in the most recent ACCP guidelines, albeit with a conflicted expert panel and caveat that it may be "less effective" than LMWH.

The most recent data that seems to support/provide momentum for this shift seems to be the EPCAT trial, where ASA was shown to be non inferior to LMWH. However, the trial seems to have several major flaws making it less generalizable. Additionally, ASA was studied for extended prophylaxis and not for the immediate post-operative period.

As someone who frequently consults and/or acts as the primary perioperative manager for orthopedic patients, I am essentially making an implicit recommendation for ASA as post-operative DVT prophylaxis by allowing this in my patients.

Are there other residents/attendings with similar concerns, and what have you or your department/institution done to reconcile differences in opinion between IM/Ortho on this subject?

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[nlax30]

I'll have to look into that as I'm. It familiar with that trial.

And I have not seen any of ortho guys use ASA, currently they either do Coumadin or LMWH.

 

[tweaked17]

I'll have to look into that as I'm. It familiar with that trial.

And I have not seen any of ortho guys use ASA, currently they either do Coumadin or LMWH.

Are you referring to the immediate post-operative period (i.e. before discharge) or extended prophylaxis (10-35 days post-op)?

Regarding the data, the EPCAT (Annals 2013) and PEP (Lancet 2000) trials seem to have given the most momentum to this movement, but that is only my opinion/observation. In reality, I think it was the change in the 2012 ACCP guidelines (which SCIP measures are based on) to now allow ASA as an option. That was a roadblock difficult to circumvent until recently.

 

[nlax30]

Both.

At least where I did my IM residency a lot of these were admitted to us, but we let ortho basically run the show and from what I remember the ones we worked with either used Coumadin or lovenox depending on who it was.

 

[nlax30]

http://www.medscape.com/viewarticle/778186_2

 

[tweaked17]

http://www.medscape.com/viewarticle/778186_2

I did read that excellent appraisal of the literature by those two pharmacists, which still left me with the question underlying the topic: How did this become standard of care for post-operative prophylaxis in orthopedic cases?

Thanks for your input, I hope to gather some more opinions.

 

[dozitgetchahi]

I'm seeing LMWH or, increasingly, rivaroxaban.

Not much aspirin.

 

[tweaked17]

I'm seeing LMWH or, increasingly, rivaroxaban.

Not much aspirin.

I was also seeing rivaroxaban (at discharge) more frequently. Aspirin seems to have not only replaced that, but crept right up to the perioperative period.

 

[bleeker10]

One of the joint attendings in my residency program uses a full strength aspirin a day with Ted hose for four weeks. He switched from Xarelto due in part to this study: http://jbjs.org/content/96/3/177
Unfortunately we haven't been able to procure mobile SCD machines for patients to rent for four weeks

 

[Bostonredsox]

Lmwh is the only option I've seen. Occasionally 325 Asa but in not sure the data backs the Asa choice

 

[Raryn]

Lmwh is the only option I've seen. Occasionally 325 Asa but in not sure the data backs the Asa choice

Rivaroxaban I've seen. Think I saw ASA once, but the guy had recent hematuria and the doc was gunshy about causing more.

 

[Trogghunter]

Lmwh is the only option I've seen. Occasionally 325 Asa but in not sure the data backs the Asa choice

Ortho at my institution doesn't use ASA. Majority are lovenox. I asked a senior resident about that exact guideline and per him the ortho attendings don't buy those guidelines and neither do the surgical icu attendings or Gen med attendings. This is at a pretty big university program fwiw