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  • Prevention of post-discharge venous thromboembolism in patients with rheumatoid arthritis undergoing knee or hip arthroplasty: a continuing matter of debate

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Prevention of post-discharge venous thromboembolism in patients with rheumatoid arthritis undergoing knee or hip arthroplasty: a continuing matter of debate
  1. M T NURMOHAMED,
  2. B A C DIJKMANS
  1. B A C DIJKMANS
  1. Department of Rheumatology
  2. Free University Medical Centre
  3. and Jan van Breemen Institute
  4. Amsterdam, The Netherlands
  5. Slotervaart Hospital
  6. Amsterdam, The Netherlands
  1. Dr M T Nurmohamed, Department of Rheumatology, Free University Medical Centre, Room B 417, PO Box 7057, 1007 MB Amsterdam, The Netherlands m.nurmohamed{at}janvanbreemen.nl

https://doi.org/10.1136/ard.60.10.905

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    Patients undergoing major hip or knee surgery are particularly prone to postoperative venous thromboembolism (VTE)—that is, deep venous thrombosis (DVT) and pulmonary embolism (PE). Without thromboprophylaxis, the incidence of DVT in such patients is more than 50%, and fatal PE occurs in 1–6%.1 These data are based on studies in which, predominantly, patients with osteoarthritis (OA) were investigated.

    It is not known whether or not there is a significant difference in the risk for developing VTE between patients with rheumatoid arthritis (RA) and those with OA undergoing major orthopaedic surgery as adequate investigations are lacking.2

    Thromboprophylaxis during hospitalisation

    During the past three decades, numerous investigations documented the efficacy of unfractionated heparin, pneumatic compression, warfarin, and low molecular weight heparin (LMWH) in reducing the incidence of postoperative VTE.

    Nowadays, LMWH is the most commonly applied thromboprophylactic agent in most orthopaedic surgery units in Europe. The evidence for the efficacy and safety of LMWH is derived from (large) trials, in which, predominantly, patients with OA were studied. Although these studies encompassed only a limited number of patients with RA, LMWH is also commonly used in patients with RA as thromboprophylaxis.

    However, not withstanding the use of preventive pharmacological thromboprophylaxis, there is still a considerable rate of asymptomatic DVT, approximately 15–20%, at the time of hospital discharge.3

    Is post-discharge (venous) thromboprophylaxis needed?

    Despite this high residual rate of DVT and laboratory evidence of continuing coagulation activation up to six weeks or longer after the operation,4 there is no consensus about whether and for how long thromboprophylaxis should be given after hospital discharge in patients with OA or RA who have undergone major orthopaedic surgery.

    An argument used against prolonged thromboprophylaxis is that most DVT occurring in the post-discharge period is symptomless and of unknown clinical significance. However, others argue that some of these asymptomatic thrombi will ultimately …

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