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JU INSIGHT Apixaban vs Enoxaparin for Postsurgical Extended-Duration Venous Thromboembolic Event Prophylaxis: A Prospective Quality Improvement Study
By: Mary E. Westerman, MD; Kelly K. Bree, MD; Pavlos Msaouel, MD; Janet Baack Kukreja, MD; Cheryl Mantaring, PA-C; Innocent Rukundo, PA-C; Martha Garcia Gonzalez, MS; Justin R. Gregg, MD; Kelly N. Casteel, MD; Surena F. Matin, MD | Posted on: 01 Oct 2022
Westerman ME, Bree KK, Msaouel P, et al. Apixaban vs enoxaparin for post-surgical extended-duration venous thromboembolic event prophylaxis: a prospective quality improvement study. J Urol. 2022;208(4);886-895.
Study Need and Importance
Venous thromboembolic events (VTEs) are a major cause of morbidity following abdominopelvic oncologic surgery. Enoxaparin, a subcutaneous injectable low molecular weight heparin, is commonly used for extended-duration prophylaxis (EP), but has been associated with noncompliance. Newer direct oral anticoagulants have not been prospectively studied in the urologic oncology post-discharge setting. We designed a quality improvement project using Deming’s plan-do-study-act cycle to improve compliance with extended-duration VTE prophylaxis following abdominopelvic oncologic surgery and secondarily test the hypothesis that apixaban is noninferior to enoxaparin for EP (see Figure).
What We Found
A total of 161 patients were discharged with enoxaparin during the baseline period and 154 with apixaban in the intervention period. Safety events (symptomatic VTE or major bleed) occurred in 3.1% vs 0% of patients receiving enoxaparin and apixaban. The absolute risk difference of 3.1% (95% CI: 0.043%-5.8%) met the prespecified noninferiority threshold (p=0.028 for apixaban superiority). Compliance events occurred in 33.5% of enoxaparin patients and 14.3% of apixaban patients (p=0.0001).
Limitations
Although our baseline and intervention groups are well balanced, this is not a randomized controlled trial, so there may be unmeasured confounding. In addition, compliance events were broadly defined and included patient self-report via survey. Not all patients completed the survey. In addition, the availability of apixaban copay assistance may have reduced the number of compliance events.
Interpretation for Patient Care
Apixaban is safe and effective for prevention of VTE after major abdominopelvic oncologic surgery. Patients should, at minimum, be offered the option of an oral EP agent