Aspirin toe-to-toe with LMWH injection in orthopedic trauma

Plain oral aspirin provided as good thromboprophylaxis as conventional low molecular weight heparin (LMWH) injections in a large PREVENT CLOT randomized trial in patients with various traumatic fractures.

Aspirin met the criteria for non-inferiority to enoxaparin for all-cause mortality at 90 days (0.78% vs. 0.73%, P.<0.001 for non-inferiority below a margin of 0.75 percentage points) from a trial of more than 12,000 patients by investigators led by Robert O'Toole, MD, an orthopedic trauma surgeon at the University of Maryland School of Medicine in Baltimore.

Rates of bleeding complications (13.72% vs. 14.27%, respectively), non-fatal pulmonary embolism (1.49% for both), and other serious adverse events were also similar between treatments. . Only the incidence of deep vein thrombosis (DVT) was significantly worse with aspirin (2.51% vs. 1.71% with LMWH), the researchers reported. New England Journal of Medicine.

“Many patients with fractures are likely to strongly prefer taking daily aspirin to injections. Both were found to produce similar results in preventing the most serious consequences of blood clots.” We anticipate that the findings from the trial will have a significant impact on clinical practice and may even change the standard of care.”

Standard LMWH thromboprophylaxis takes the form of injections that cause pain and bruising in some patients. In contrast, oral aspirin is relatively easy to administer and inexpensive to start.

Dr Matthew Costa of the University of Oxford, England, Accompanying editorial PREVENT CLOT should encourage guidelines to be updated to include aspirin as an option for venous thromboembolism (VTE) prophylaxis in trauma patients. provided “compelling evidence that readily available and inexpensive oral agents are a viable alternative to injectable pharmacological prophylaxis.”

Costa nevertheless noted a slight excess of DVT in the oral aspirin group.

“DVT is not as serious as an apparently fatal pulmonary embolism, but it is not a trivial problem. It can cause severe pain and swelling,” he warned. .

The CDC is Up to 100,000 people VTE kills every year in the United States. These blood clots are a well-known complication after surgery. Outside of healthcare-acquired cases, it has also been associated with long-distance travel, pregnancy, and cancer.

O’Toole and colleagues conducted PREVENT CLOT at 21 trauma centers in the United States and Canada. Participants were recruited from his 2017 to his 2021 and included 12,211 adults hospitalized with pelvic fractures or leg or arm fractures requiring surgery, excluding hand and forefoot fractures. I was.

The mean age of the study cohort was 44.6 years and 62.3% were male. Orthopedic trauma was the only known risk factor for her VTE in her quarter of patients. 0.7% had a history of VTE and 2.5% had a history of cancer.

Individuals were randomly assigned to enoxaparin (30 mg twice daily) or aspirin (81 mg twice daily). After discharge, patients continued to receive thromboprophylaxis according to the clinical protocol of each hospital. Therefore, no period of thromboprophylaxis was mandated, he conceded O’Toole’s group.

Still, the duration of prescriptions for aspirin and LMWH was comparable. The patient received an average of 8.8 in-hospital thromboprophylaxis doses, and at discharge he was prescribed 21 days of thromboprophylaxis for a median. Adherence he reached 87.4%, according to the study authors.

They also noted that the open-label conduct of the study may have influenced secondary outcomes. In addition, the primary endpoint was changed from pulmonary embolism-related death to all-cause mortality (changed after enrollment, but without knowledge of trial outcome).

Nevertheless, in the surgical setting, the benefits of aspirin thromboprophylaxis appear to extend beyond total joint arthroplasty. it is still a challenge.

“Further research is needed to determine whether aspirin should also be considered for VTE prophylaxis after other types of surgery and for non-surgical patients with risk factors for VTE.