Apixaban versus enoxaparin in patients with total knee arthroplasty A meta-analysis of randomised trials

It was the objective of this study to systematically compare the effects of apixaban versus enoxaparin in patients following total knee arthroplasty (TKA). A systematic search of Medline, EM BASE, Cochrane Central Register of Controlled Trials was conducted. Eligible studies were prospective, randomised control trials (RCT) of apixaban therapy, comparing with enoxaparin, in patients who have a high risk of venous thromboembolism (VIE) after TKA. Three RCTs involving 7,337 individuals were identified, of whom 4,057 were treated with apixaban 2.5 mg once daily, and 3280 were subcutaneous enoxaparin (40 mg once-daily or 30 mg twice-daily). Meta-analysis demonstrated the odds ratio (OR) for the composite of major VIE (proximal deep-vein thrombosis and pulmonary embolism) for apixaban versus enoxaparin was 0.47 (95% confidence interval [CI]: 0.27 to 0.82, 0.6% vs. 1.2%) and 2.09 (95%CI: 0.99 to 4.45, 0.6% vs. 0.3%), respectively. All-cause mortality occurred in 0.2% of the apixaban group versus 0.09% of the enoxaparin group (OR=1.74; 95%CI, 0.51 to 5.95). With respect to safety outcomes, apixaban was associated with a lower major bleeding rate than enoxaparin (OR=0.55, 95%CI: 0.32 to 0.96). No significant differences were detected between two strategies in other endpoints of safety profile analysed: clinically relevant non-major bleeding, raised hepatic transaminase enzyme or bilirubin concentrations and arterial thromboembolic events. In conclusion, apixaban is non-inferior to subcutaneous enoxaparin when used for the same duration, with considerable advantage regarding safety profile of major bleeding after TKA.