Practical use of apixaban in the prevention of venous thromboembolism after total knee or hip replacement.

Apixaban is an anticoagulant drug that acts by directly inhibiting coagulation factor Xa. Unlike low-molecular-weight heparins and fondaparinux, apixaban can be taken orally; in contrast to vitamin K antagonists, its clinical use does not require dose adjustments according to coagulation monitoring. Apixaban in a regimen of 2.5 mg twice daily has been approved in Europe for the prevention of venous thromboembolism in patients undergoing elective total hip or knee replacement. This approval was based on the results of two large phase III trials showing that, compared to the European approved regimen of enoxaparin for total hip and knee replacement (i.e., 40 mg once daily starting preoperatively), apixaban 2.5 mg twice daily initiated 12-24 hours after wound closure was more effective in preventing venous thromboembolism, without increasing the risk of bleeding. This apixaban regimen may therefore represent a convenient alternative to conventional anticoagulant drug regimens in the prevention of venous thromboembolism in this surgical setting. However, there are several precautions that prescribers should take into account before using this drug regimen. In this article, various points are considered, notably bleeding risk and the use of this novel oral anticoagulant in special populations or in the context of neuraxial anesthesia.