Venous thromboembolism (VTE) is a relatively frequent complication in hospitalized patients, especially in those with risk factors. The benefit of using direct oral anticoagulants (DOACs) for prevention is controversial. This systematic review was performed as part of the American Society of Hematology (ASH) guidelines on VTE, developed in partnership with McMaster University. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Epistemonikos were used as data sources from date of inception to November 2019. We included randomized trials in patients hospitalized for an acute medical disease, evaluating any DOACs vs other pharmacological prophylaxis, and included 3 trials with low risk of bias. We analyzed the effects of DOACs vs low-molecular-weight heparins (LMWHs) at 2 different time points: at the end of the short-term treatment phase (both drugs given for the same period of time) and at the end of the extended prophylaxis period (extended DOACs vs a shorter course of LMWHs). We observed that the use of DOACs did not reduce the risk of pulmonary embolism or symptomatic deep venous thrombosis (DVT) in comparison with LMWHs. However, the risk of major bleeding was slightly increased. Additionally, we observed that the benefit of DOACs previously reported was largely based on the reduction of asymptomatic DVT and was not apparent when only symptomatic events were considered. The use of DOACs in hospitalized medical patients slightly increases the risk of major bleeding with no appreciable benefit over LMWHs.
© 2020 by The American Society of Hematology.
Conflict of interest statement
Conflict-of-interest disclosure: Full conflict-of-interest declarations for all of the authors of this review are available in Schünemann et al. F.D. and K.B. have received funding from DOAC manufacturers. The remaining authors declare no competing financial interests.
Comparative effectiveness of low-molecular-weight heparins versus other anticoagulants in major orthopedic surgery: a systematic review and meta-analysis.Pharmacotherapy. 2012 Sep;32(9):799-808. doi: 10.1002/j.1875-9114.2012.01106.x. Epub 2012 Jun 28. Pharmacotherapy. 2012. PMID: 22744711 Review.
Venous thromboembolism prophylaxis in medically ill patients: a mixed treatment comparison meta-analysis.J Thromb Thrombolysis. 2018 Jan;45(1):36-47. doi: 10.1007/s11239-017-1562-5. J Thromb Thrombolysis. 2018. PMID: 29043538 Review.
Editor's Choice - A Systematic Review and Meta-Analysis of the Efficacy and Safety of Anticoagulation in the Treatment of Venous Thromboembolism in Patients with Cancer.Eur J Vasc Endovasc Surg. 2019 May;57(5):685-701. doi: 10.1016/j.ejvs.2018.11.004. Eur J Vasc Endovasc Surg. 2019. PMID: 31097186
Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair.Cochrane Database Syst Rev. 2016 Mar 30;3:CD004179. doi: 10.1002/14651858.CD004179.pub2. Cochrane Database Syst Rev. 2016. PMID: 27027384 Review.
Extended Anticoagulant and Aspirin Treatment for the Secondary Prevention of Thromboembolic Disease: A Systematic Review and Meta-Analysis.PLoS One. 2015 Nov 20;10(11):e0143252. doi: 10.1371/journal.pone.0143252. eCollection 2015. PLoS One. 2015. PMID: 26587983 Free PMC article. Review.