July 31, 2024 • 39 mins
In this episode, we delve into the critical topic of VTE prophylaxis in knee replacement surgeries. Special guest Dr. Atul Kamath from the Cleveland Clinic joins the discussion to share insights from a recent JBJS article advocating for low-dose aspirin as the safest and most effective prophylaxis for VTE after total knee arthroplasty across all patient risk profiles.
Dr. Kamath, a seasoned orthopedic surgeon with an impressive academic and clinical background, provides an in-depth analysis of the study's methodology, results, and implications. The conversation touches on key points such as the rising trends in aspirin use, the comparative efficacy of different anticoagulants, and the cost benefits of using aspirin.
Listeners will gain valuable knowledge on how this study could potentially shift clinical practices towards using aspirin for DVT prophylaxis, the importance of rapid recovery protocols, and the overall impact on patient outcomes. This episode promises to be a comprehensive guide for orthopedic professionals interested in the latest advancements in knee replacement surgery and DVT prevention.
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Episode Transcript
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(00:00):
Music.
(00:11):
Of the Shelburne Knee Center Podcast. We're here with Scott Bauman,
my co-host tonight for another episode covering another jerk replacement and
knee replacement topic with another great guest.
So thank you for joining us. If you want to find us, you can find us wherever you get your podcasts.
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You can also email us if you'd like to ask us any questions or suggest any other
topics you'd like to hear about at the SKC podcast at gmail.com.
If you haven't, we highly recommend you go back to last week and listen to the episode.
We had a great guest on. We had Claudette Lejeune from NYU in New York City,
and we talked about something we really haven't discussed yet on the podcast,
a little bit different of a topic.
(00:54):
It was the ethical considerations of declining surgical intervention,
and it was really balancing the mix of the medical, legal, and financial implications
of taking care of patients in your orthopedic setting, especially with the high-risk population.
So, So if you haven't, before you listen to this episode, go back to last week's
episode and listen to Dr. Lejean discussing that topic.
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If you heard that or any of our other topics and you'd like to leave us a five-star
review or a comment for those that come behind you, please do that as well.
Tonight, we're going to be talking about DBT prophylaxis, VTE prophylaxis, and joint replacement.
And this all comes from a JBJS article that is now in press.
Low-dose aspirin is the safest prophylaxis for prevention of venous thromboembolism
(01:36):
after total knee arthroplasty across all patient risk profiles.
And I know this is something that I haven't made the jump to yet and use an
aspirin as my DVT prophylaxis.
And I read this study with great interest to see whether it might change my mind.
So one of the authors from that manuscript is on the show tonight.
Dr. Atul Kamath is at the Cleveland Clinic in Cleveland, Ohio.
(01:58):
He went to medical school at Harvard Medical School, followed that up with a
residency in orthopedics at the University of Pennsylvania and a fellowship
in adult reconstruction at the Mayo Clinic.
He's the director of the Center for Hip Preservation at the Cleveland Clinic.
He's a professor of orthopedics at that institution, as well as Case Western Reserve University.
And he is a clinical innovation lead for Orthopedic and Rheumatologic Institute
(02:20):
at the Cleveland Clinic as well.
So, Dr. Atul Kamath, thank you for coming on with us tonight.
And we appreciate being able to have you on the show.
Thanks for having me. I'm excited to talk about this topic. and hopefully I
can convince you to switch to aspirin here.
Absolutely. So tell us about how you became interested in this topic.
What was your way into this specific topic from a research perspective?
(02:43):
Now, DVT prophylaxis, I think, is such an important topic, though,
just orthopedics in general.
And I think, obviously, joint replacement, given some of the higher risks with
patient population and the nature of the surgery, I think it's important to
kind of continuously look at DVT prophylaxis.
(03:04):
I do think over the last couple of decades, prophylaxis has come a long way just in general.
We're continuing to explore it, but I think looking at certain types of DVD
prophylaxis, such as Coumadin,
which had been highly used in orthopedics and joint replacements in the last
(03:25):
decade or so, in certain centers has fallen out of favor.
And then you look at other ones, novel anticoagulants that have really grown
in popularity in the cardiac space and other surgery spaces,
and then obviously have made their way into orthopedics.
So you have these different major trends. And throughout this time,
aspirin has been a choice of DVT prophylaxis.
(03:48):
And certainly from the standpoint the goal was
to understand temporal trends over time of using aspirin but
then kind of look at it you know versus maybe more
historical but then also specifically for this paper some
of the more newer anticoagulants and you know just really look at it specifically
in low and high risk populations so the topic being very complex the the basic
(04:12):
goal and the interest of our group was to look at the utility of using aspirin
And, you know, it's simple, it's cheap,
it's predictable, using it in low risk and high risk populations in joint replacement
and, and looking at that from that perspective.
So, you know, personal interest of mine was to see that because my practice,
and it probably sounds like it differs a little bit from yours is to use,
(04:34):
you know, aspirin is almost the default pathway.
And, and again, just taking it. So it's a personal interest to see how that fares.
And then also just broadly to see some of the trends in orthopedics and,
you know, not just safety for protection, but, you know, other things like complications
and hospital admissions and other sort of health systems type questions.
So a number of questions were kind of sparked by using this topic.
(04:56):
But again, that's sort of the overarching theme of
you know, why we wanted to tackle this particular. I have medical students with
me every month, and this is a topic that I try to cover every month with medical students,
just because it's kind of, it allows me to talk about a bunch of different things
that I want to talk about over the course of their month-long rotation with me all at the same time.
(05:16):
Obviously, I want to talk about risk factors and complications that can happen
from orthopedic surgery and just kind of general surgical principles of which
DVT prophylaxis is a really important one, especially with lower or extremity surgery.
I want to talk about the pharmacology of all these different agents.
So I'd have them look them up and then they tell me what they found.
And I see if I can remember if that's right or not before we move on to the next topic.
(05:40):
And just talking about the pluses and minus of each of those when they try to put it into practice.
I then put it on to them as a way to talk about research also is if you're going
to design a study for DVT prophylaxis, how would you design it?
And one of the reasons I like to talk about that is because this is not an easy
topic to study effectively and to get any good information out of for something
(06:03):
that is relatively uncommon.
Like venous thromboembolism after surgery, relatively speaking anyway,
and to have so many different agents that are possible, DVT prophylaxis agents
that you could study to design a well-done level one randomized controlled trial
with several different agents.
You would need thousands of patients to be able to show any statistically significant
(06:27):
and or clinically significant differences.
Just presents some challenges from a research perspective. So kind of give us
a little bit of background for what's out there.
And before you did this study, kind of what's out there that led you to say,
you know what, here's the way I think we can look at this problem differently
and hopefully answer this question.
Yeah, that's great. And I think, you know, what's exciting about your research
(06:50):
group is you're, you know, continuously looking at these topics.
And a podcast like this is a phenomenal way to kind of explore different topics.
But you're right, this is a huge, it's a complex topic.
And we took it from the perspective of can we use a large multi-center database?
I mean, this study, I don't know, I don't recall exactly, probably at least
(07:11):
60 centers were involved in the data that was called for this study.
But, you know, when we're talking about looking at a collaborative network that
includes almost 90 billion patients, I mean, this is a way we said,
listen, you know, we don't have the budget.
And also, you know, there's challenges to kind of do some sort of very large
scale prospective trial.
So we said, let's take a fairly thorough database, you know,
(07:33):
with enough power to do some propensity score matching and then,
you know, tease out those buckets, like I said.
So I think, you know, and hopefully we'll go into challenges of this particular
study design, but I do think there's challenges to anything,
but we thought, hey, let's use a large data set.
Let's try to tease that out and get enough patients in enough buckets to get
some meaningful answers.
I do think also there are some historical trials where a particular novel anticoagulant
(08:02):
or a particular DBT prophylaxis medicine was used in a level one prospective blinded trial.
But again, for me, sometimes those studies are just biased to looking at two
different medications or did not include an aspirin arm per se or just high-risk patients.
So we wanted to also be taking low-risk patients, high-risk patients,
(08:25):
taking patients on different medications.
And again, that for us required looking at a very large database.
I would also say that some of the studies, and again, there's conflicts of interest
with any particular study, but some of the studies historically have...
Been designed or developed by manufacturers or pharmaceutical companies.
So there's some inherent bias.
(08:47):
And again, well, you might say, hey, what's your bias? And I'm an orthopedic surgeon.
I don't have an interest in a particular pharmaceutical company.
However, my bias was that I use aspirin. I think one of the other co-authors,
Jay Parvizi, is also a heavy aspirin user.
And he's been a large proponent of aspirin for the last decade plus.
So you might say we have of, you know, at least two authors who come at this
(09:10):
study from an aspirin bias perspective.
And, you know, that may be an important thing to discuss as well.
You know, we do reference in the paper as well, the 2022 ICM or international
consensus meeting on BTE and for the audience and for the students and the trainees
and even surgeons out there who are not familiar with it,
I would say, take a look at that because that's sort of a global consensus meeting
(09:32):
that takes different topics,
including things like use of aspirin as a DVT prophylaxis measure and sort of
does a Delphi consensus structure to say, you know, is there best available evidence?
I would say one of the outputs of that did recommend aspirin as a VT,
as a very effective VT prophylaxis agent, including those in moderate and high risk groups.
(09:55):
So again, that, that sort of was a sort of of impetus to say,
hey, can we test that hypothesis or test that expert opinion,
consensus, review of the literature in another large scale population and go from there.
But again, that was a little bit of the study design and the purpose of using a large scale data set.
But again, I think worthwhile to just, as I said, highlight some of the either
(10:19):
personal or the sort of the perspective behind it.
I'm saying, well, let's see how good aspirin lines up against other measures. it's episode.
Now, you mentioned some trends towards aspirin and the international consensus
coming to that conclusion, as well as your own personal thoughts on this topic.
So, and I'm not sure how long you've been in practice, but is this something
that you have been utilizing for DVT prophylaxis, meaning aspirin,
(10:43):
or were there other agents that you were using that you had switched to after
diving into this topic more?
Yeah, so that's an excellent question. And I kind of alluded to a little bit
of my preamble because, you know, in, in the last decade of practice,
I've used predominantly aspirin, but I had used some Lovenox as well for,
(11:03):
for my joint replacements.
I had trained, and this is going back a little bit of time, but I had trained
at some institutions that, for example, in Philadelphia, where Buminin was a
standard for a lot of the joint replacements.
And I do recall, you know, as a trainee or, you know, resident,
you know, daily, you know, looking at iron levels, trying to titrate Cupid.
And again, of course, patients were in the hospital several days at that point,
(11:26):
but it was something where now a little bit, it's, you know,
aspirin's plug and play. I give it to them and I kind of like that convenience.
I always, I think, you know, another topic for discussion here,
and I always consider this and, you know, it's, it's not simply preventing DBT
as we're focusing on here, but it's also looking at things like bleeding complications
and looking at wound drainage.
(11:47):
So I always, and again, this is my perspective and my take was that aspirin
had a really nice profile of.
In my hands, and then, you know, certainly in talking with others,
it had a nice profile of preventing DVT, but then also had a nice profile as
well for minimizing complications such as bleeding, any sort of undue wound drainage.
(12:08):
And so, and then again, the ease of dosing, the ease of monitoring,
the ease looking at that from that perspective sort of was a happy medium from all perspectives.
But I do think, you know, again, bringing that to the table,
aspirin has been my predominant dvt prophylaxis measure for patients now if someone comes in.
You know on you know having a stent a year ago and they were on plavix plus
(12:31):
aspirin i mean i don't rock the boat too much on people who come in with specific
regimens for their you know cardiac medications or some other reason why they
would be on a different type of
anticoagulant so i will tend to keep those patients on those medications.
But again, someone who comes in naive off of a chronic anticoagulant,
(12:52):
I will use aspirin as the default rather than using something else.
So, and that's a little bit of my practice and that's been going on for a number of years. Yeah.
Yeah. Mine's kind of changed over time. When I first came into practice,
my partner was using was using Lovenox injections for three weeks at that time,
which is longer than I had experience with where we did it for two weeks in
(13:16):
residency and fellowship.
So I didn't want to be too disruptive. So I just kind of said,
okay, I'll roll with that.
There were some problems with it being expensive, some problems with people
not wanting to do the injections or not feel comfortable doing the injections, of course.
And then you have the occasional patient that bleeds and the first thing you
have to do is stop your anticoagulant. Then you're concerned that.
They're not protected from VTE, but we can't have them bleeding either and all
(13:40):
these issues that you bring up.
So that partner that I had subsequently went on to a different practice.
So I then switched back to two weeks, which everybody was happy about that we'd moved to two weeks.
And then after a while, people were just tired of the injections for the most
part. So I switched to Rivaroxaban over to Xarelto.
And in the last several years, that's been my agent of choice.
(14:02):
I've used aspirin very infrequently. I leave people on it if they're already
on it, but I haven't been using it for the DVT prophylaxis after surgery on
a routine basis or even on a risk stratified basis.
And my main concern was I just wondered, like a lot of us do,
whether or not there was the efficacy there for aspirin versus the,
you know, the other kind of, you know, kind of quote heavy hitter anticoagulants.
(14:24):
And it's just any time you take something back away when we're treating patients,
you You get concerned that, you know, if I have a complication,
you know, two weeks later, then I wonder if I just caused that trying to get
away from something that I wasn't really having a problem with.
So I've been watching closely as more and more data has come out about aspirin,
and I've tried to be kind of a slow adopter when it comes to this.
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But, you know, I get a little bit of pressure from the hospital to decrease
costs by using aspirin. and I don't particularly like when my patients call
and say, hey, this costs a few hundred bucks that I don't really have to spend on this.
So that's where I'm really thinking about switching and I've just been waiting
for a couple more studies to come out and really for myself to look into it
(15:08):
enough to justify it to myself.
So let's dig into this study, if you don't mind, for the next several minutes
here and kind of talk about the specifics of this study.
So with that kind of as a background for the environment around VTE prophylaxis in joint replacement.
Tell us about the specific methods of your study and how you chose to evaluate this problem.
(15:28):
Yeah, so I think, you know, again, on the focus of we need some big data set
here, we use what's called the TrinetX collaborative network.
It has a number of centers, you know, and then again, probably close to 90 million
patients that are in this data set. that we decided to take a look at patients
(15:49):
receiving their total knee.
We wanted a broader timeframe, so we looked at 2012 to 2022.
And, and, and again, that was to try to see, we wanted to see trends over time
and then also try to look at, you know, rates of complications in a robust fashion.
We had, we took a look at patients at high risk for BTE and those were defined
as patients, you know, again,
(16:12):
through the international consensus meeting, these are patients who have,
you know, sort of different risk factors that would put them at higher risk,
including including things like obesity,
primary thrombophilia, things like history of stroke or COPD.
You know, there's a laundry list of things that might put someone at a higher
versus lower risk. And, you know, we really separate those.
(16:32):
After doing that, we probably had roughly close to about 50,000 patients in
each of those arms, you know, the high-risk arm and the low-risk arm.
And then with each of those arms, we try to take a look at the DVT prophylaxis.
So whether it was low-dose aspirin plus another anticoagulant,
which is the smaller groups in each one, then, you know, the majority of the
(16:54):
groups were either low-dose or the other sort of anticoagulant prophylaxis.
And these are the ones like, you know, the Warfarin's and the other ones you
mentioned as well, unfractionated heparin, the factor Xa inhibitors,
the direct thrombin inhibitors. So, you know, those were the other buckets.
And, you know, we did that for both the high-risk group and the low-risk group
and roughly probably about 20,000 patients in each of those arms of the,
(17:16):
you know, comparing the low-dose or the, you know, low-dose aspirin to the other anticoagulants.
And so those, you know, those were the ones where, you know,
we applied propensity score matching to kind of match them as well.
And some of your questions or thoughts from before, like there was looking at
characteristics such as chronic aspirin use and some other heart disease issues.
(17:38):
And so we really try to make sure that each of the buckets were comparable when
we did the propensity score matching.
And then again, you know, in terms of, you know, things like just curiosity,
we said, saying, well, what are their use of rates of aspirin versus other antipraglins in total need?
Over time. And, you know, there's a figure in the paper that you may recall that looks at,
(18:00):
you know, the increasing use of low-dose aspirin and then also,
you know, the decreasing trend over time from, you know, over the last decade
of the study, 2012 to 2022 of the other anticoagulants.
So a little bit of reflective, you know, now these are, are these just trends
in orthopedics? Is this something, but, you know, over that decade,
there was definitely a decrease in the the sort of bigger guns,
(18:22):
so to speak, of anticoagulants.
So it kind of reflected a little bit of what we had a sense of,
perhaps in the orthopedic field that, you know, there may be sort of a uptick in aspirin use.
As you know, the chest guidelines and things like that historically had been
not including aspirin, and then perhaps, you know, between the orthopedic community.
(18:44):
You know, using aspirin more or testing it out, plus some of the other guidelines
that were there. plus our academy.
I think, you know, some of those things, I think some of those forces definitely
were reflected in the fact that, you know, aspirin use both in low and high
dose aspirin use was increasing over time, specifically the low dose aspirin.
I think other kind of interesting things, if we look at it, you know,
(19:07):
the rates of DVT and P within the three months after,
DKA for all patients actually, you know, fell over time, you know,
in both DVT and P from that 2012 to 2022.
So I think it's something where the rates had come down as well.
Now, I think there's probably, and we bring this up in the discussion,
(19:28):
but is this because we're doing more rapid recovery protocols?
I don't think our patients are necessarily becoming healthier.
I think it may be a fact of probably more rapid mobilization,
probably better preoperative optimization, optimization.
But it was interesting as well, the rates of BVT and PE are overall falling.
Even in the sense in the light of now using a little bit more aspirin over time.
(19:52):
So, you know, we're not in that that specifically wasn't a conclusion that the
aspirin was the cause of this, I think it was more multifactorial.
I think it's the rapid recovery, the shorter length of stay,
the up and moving the day of surgery and all that.
So I think those were sort of more just observation type things.
And then, you know, kind of digging, you know, into the odds of actually using,
(20:13):
you know, prophylaxis, you know, even in higher risk patients,
we've found that, you know, their odds have been, you know, increasing over
time amongst even the higher risk groups.
So, you know, that was our kind of foundation, the kind of demographic propensity
matching, the temporal trends, and then also looking at the DVD trends.
Those set the stage a little bit for then specifically looking at odds ratios
(20:37):
for comparing aspirin to, you know, the other coagulants with respect to the
complication things that we were sort of discussing in the beginning. So.
Yeah, it's interesting that the same time that we're starting to shift away
from what we think are more significant anticoagulation,
we're also seeing a bit over the same time period, the appearance and the boom of tranexamic acid,
(20:59):
which all of us are worried we're going to cause DVTs when we first started using that.
So it's an interesting juxtaposition as we go to what we perceive as a little
bit lighter or of an anticoagulant, and we add a medicine that we are concerned could facilitate clot.
Formation, and the rates just keep going down, which is interesting.
(21:21):
And I think it's great information, something that I really commend the orthopedic
community for really studying in depth instead of just relying on,
you know, well, we think this is a worrisome, we think this isn't going to be efficacious enough,
you know, we're going to put it to the test with data and prove it.
And I think that's been a big improvement for all of us who do joint replacements.
(21:43):
Yeah. And I think even just not to get too much off topic, but,
you know, you bring up an excellent point about the transglaucoma acid.
I mean, it's sort of, it's been one of the game changers in joint replacement, right?
And orthopedics in the sense of, I mean, I may transfuse a patient once a year
or twice a year, and I do largely think it's probably due to transglaucoma acid, right?
I think we have better stewardship protocols, but again,
(22:06):
yeah, I mean, I always think back in designing this study, I thought back,
I did, you know, Mark Pagnano in the Mayo Clinic wrote a paper on,
and other groups have as well, on, you know, just using transedema acid,
even in high-risk patients, patients who've had cardiac histories,
and they found no really high risk of, you know, adverse events there.
(22:26):
Some of those, they found low risk of adverse events, because a lot of those
people were already on some higher level anticoagulants.
Yeah, and perhaps the bleeding control and all that. So I think whether to be
a rebel or not, or just mimic some of that spirit, it is a little bit of challenging
dogma and say, hey, you know, what is it about aspirin that may be good or not?
And again, I do think, you know, the rapid recovery protocols,
(22:49):
other things help us overall.
But I do think these trends and the efficacy that we're seeing here,
again, as best as controlled as we can, I think do still reign true or ring
true a little bit with aspirin being definitely a viable option, you know.
Dr. Kamath, I'm more of the numbers nerd around here, and hearing these methods
and reading this methodology, I thought it was great.
(23:11):
You're pulling from a system that you're measuring it by the millions is always
fascinating when you have these big data sets, and then you design a well-designed
study like you did where each arm of the study has nearly 20,000 patients.
So, first of all, great work on that, and I thought that was set up really well.
So, with all that being said, methodology-wise, can you tell us a little bit
about the main findings and the main takeaways from a results standpoint with this study?
(23:35):
Yeah. So, you know, the main results, you know, I think we talked a little bit
about, you know, the increase in the use of aspirin.
I think what was interesting and, you know, we did put together a number of
tables to try to compare, you know, different regimens like low-dose aspirin
versus the other anticoagulants.
We looked at low-dose aspirin versus rivaroxaban specifically.
(23:57):
And then also things like low-dose aspirin versus low-dose plus a combined anticoagulant.
So we tried to look at different combinations, and I would ask the readership
or the listenership to maybe dive into those tables to kind of look at the specific things.
But, you know, when we look at, you know, complications, so to speak,
(24:18):
we look at, you know, the main title was DVT and PE, but we looked at other
things like hemorrhage or hematoma or GI bleeding, even things like mortality, revision surgery,
ED visits, readmission.
So we try to look comprehensively for all those comparator groups.
And when we look at, for example, low-dose aspirin versus other anticoagulant,
(24:41):
the odds ratios were generally in favor of the low-dose aspirin groups.
I think there was maybe one where it was sort of a wash. I think it was,
for example, PJI was really no different between the two groups.
The confidence in Roll Cross won for that group. But every other parameter for
(25:01):
the low-dose versus other anticoagulants,
across the patient profiles were actually in favor of the low-dose aspirin,
some a little bit stronger.
Like for example, hemorrhage was more strongly in favor of the low-dose aspirin group.
And that gets to my comment before a little bit, you know, qualitatively,
(25:22):
I've always seen less wound complications, less bleeding at the surgical site
with using aspirin versus the other anticoagulants.
And then again, it's nice to see that you have an odds ratio of 0.25 or 0.23
three for things like DVT-PE.
So fairly protective on both ends of the spectrum.
And then other sort of other big, bad complications, mortality.
(25:43):
Stroke, things like that, MI really were in favor or certainly showed that aspirin
was effective in kind of mitigating those complications as well.
And again, this is in the first 90-day period, so fairly comprehensive.
It's not just in the the first two weeks or, you know, six weeks that we looked
at, we sort of took it out to the three-month period.
(26:04):
And then, like I said, you know, the listenership can kind of dig into the meat
of the other kind of comparator groups, including things like rivaroxaban only,
and then again, some of the other parameters.
So I do think, you know, there are within the limitations of trying to get as
many patients as possible.
And despite having tens of thousands of patients, I think you can always kind
(26:27):
of challenge your question.
And then even, I think there may be, you know, folks who may,
you know, look at our propensity matching or other parameters,
but, you know, again, like I said, the best we could do with the study available data points,
fairly robust study, and again, points that, you know, low-dose aspirin definitely performs well.
So I think that's sort of a major, you know, findings of the study,
(26:49):
you know, that, you know, both low-risk and high-risk patients in the low-dose aspirin group.
Had decreased odds of the bleeding, the complications, and even things like hospitalizations.
Yeah, I thought all those results were right on the money. The things I was
worrying about, people are going to get more DVTs? No.
People are going to get more PEs? No. Am I going to kill somebody if I use this
(27:10):
medicine instead of the other ones that I'm using?
Absolutely not. Do I need to risk stratify people? And it seems like the answer
is pretty convincingly no.
And then, of course, we can go down the line to the complications as well.
And even And those things are equal enough that we can start to assess cost as well.
I want to bring cost down like everybody else, but when somebody comes to me
(27:31):
leading with how does this cut cost,
I always respond with how is this beneficial to the patient before we start
thinking about how it benefits me or how we think about how it benefits the
healthcare system cost-wise.
And just across the board, the asthma performed in all categories as well as
causing less complications. So great paper.
(27:52):
And a lot of times when we get these big database studies,
one of my big frustrations with studies like this, to be honest with you,
is it's a lot of times when we do a lot of these big element studies with a
bazillion patients in all to find that there's no difference in anything and
that we haven't learned much.
So I was happy when I saw the results of this study and really reviewed them
(28:12):
closely in preparation for this to see that this is some really good information
that we can use in our practices.
So I guess I'll pin you down now and say yes or no.
Can we confidently say that aspirin is our preferred DVT prophylaxis agent in
all risk groups as a result of this study?
Yeah, I think, you know, from the standpoint, it goes back to a little bit of,
(28:34):
you know, we're creatures of habit too, right?
We like certain things, you know, and then again, you know, all it takes is
one patient to have a complication, a DVT or something that sometimes our emotional,
it sways our emotions on the next hundred patients may, you know,
may change our practice.
But I think sticking with this large database study that's well-controlled and
(28:54):
well-designed and really supports the use of aspirin, I would say that we can
definitely continue to support this. It doesn't mean this ends here.
I think it's worthwhile to study this, again, especially as we look at things
like rapid recovery, and then again, more complex and more comorbidities with our future patients.
These are all things to continuously look at this. So I don't think we rest
(29:17):
or I would say I rest on, okay, this is the be all end all in my practice.
I'll continue to to challenge this.
I do think there's other regional and other biases and other kind of understanding.
I will tell you that in response to this paper, a number of folks from around
the globe actually have written to me, and some have written letters to the editor,
some from Europe who do not use aspirin in certain countries and then don't
(29:40):
believe in it, and then some that are in support of it. Again,
so it's not just a US question, it's a global question.
But to the point of a very efficacious medication that has a great profile on
both ends of the spectrum, leading to clotting.
And then again, to your point about cost, if it's cheap, if it's readily dosed,
(30:00):
if it's now better understood and it's best for the patient as well as ease
on the health system, I think it's sort of a win-win.
So I would say that aspirin, you know, in my mind clearly has a strong role
and, you know, really should be given consideration as first-line therapy for
DVT prophylaxis and total knee replacements.
You made a good point about this not being just a U.S. problem.
(30:23):
It's more of a global problem, but bringing it back to the local nature to it.
I know you said you and I think you said Dr.
Parvisi was also using aspirin even prior to this study.
But, you know, I was looking at the author line. It looks like there's seven or eight authors there.
Have you talked to any of your co-authors or anybody within your own health
system that have since changed their prophylaxis to aspirin based on this study?
(30:45):
Yeah. So some of the coauthors, one is more on the statistical side.
But I would say just in general, our institution is a heavy aspirin use institution.
And we tried to standardize as well. We have a lot of surgeons.
We have a lot of thousands of joint replacements going on. So we try to standardize a lot of things.
But our general consensus is aspirin for primary and actually a number of the
(31:10):
revision surgeries as well.
And so again, we have certain parameters where we'll use the other anticoagulants,
but in general, the aspirin has become the default at our institution.
I do think in chatting at conferences, chatting with different surgeons here
and there in different venues, and then also in the spirit of putting this paper
together, I do think aspirin has become more widely accepted.
(31:33):
And again, I don't appreciate, Again, this is more anecdotal,
but in discussions with folks on the small scale, little conversations,
visiting a hospital or at a conference, they're experiencing the same beneficial
safety profiles that we're seeing here in the study.
So I do think, you know, a lot of folks have moved towards this.
And again, I'm a big advocate of it. I've always has been.
(31:55):
But I think this really supports that and at least opens the door for discussion
and at least opens the door for looking at our data and saying,
hey, does this does this ring true with my practice?
Does this is this an opportunity to understand this? And then again,
maybe start slowly with patients that you think may be the lowest risk of introducing
aspirin and not having complication, and then start building that up or working
(32:18):
that into more routine practice as your health system,
as you, as the patients get comfortable with this type of modality.
I'm going to go rapid fire at you with a few questions. And these,
these are going to be kind of short answer questions.
So we can cover a bunch of stuff in a short period of time, little nuance things.
Short one. Do you use this with TXA? I assume the answer is yes from our,
(32:39):
from our discussion so far.
Yeah. Standardized against a one gram on incision, one gram on closure.
And this is pretty much for everyone. Yeah. I think there's some rare contraindications
like color blindness or things like that.
I mean, I, but again, it's again, the default, everyone gets it.
But TXA and aspirin pretty much.
How about, how about bilaterals and revisions?
(33:00):
I tend to do very few bilateral simultaneous bilaterals. I'll tend to stage
them, but, but again, for, for closely staged.
And then again, some of my partners do a little bit more bilateral work.
We'll, we'll tend to use aspirin as well, or primaries for revisions.
You know, obviously, as you know, there's a whole spectrum of revision surgery.
(33:21):
You know, again, there's simple ones like the poly swap, so to speak,
versus the big, huge, massive cones and stems and things like that.
I tend to bias my use of Lovenox more in the more bigger surgeries.
And then again, more quote unquote simpler revisions, get aspirin 325 BID for six weeks.
(33:44):
For your standard patient cell, it's 81 milligrams twice a day. Is that correct?
Yes. And I, and I, you know, I use it for six weeks.
Now there are some in our group who do it as short as four weeks,
but that is something I think that was, you know, asked how's my practice changed
over time, but I have not changed the duration of using it, sort of starting it some time ago.
(34:06):
So I think, you know, probably can truncate it. Whereas I started 325 BAD for six weeks.
Years ago, I went down to 81 BID. I still kept it at six weeks now.
Perhaps maybe I could truncate it further or those who are running around a
clinic in two weeks, maybe I can even stop it then.
But that's just, again, my internal caution.
(34:27):
And again, as we dive into future studies,
maybe there's some way to very specifically look at that question.
Can we do it for two weeks and get them off? And I don't have that answer for
you today, but it would be interesting to say that. I just don't have the confidence
to say that with the available data. Yeah.
Rolling on with rapid fire questions and answers. Do you feel,
do you use this with anti-inflammatories in your post-op patients?
(34:49):
Yeah. Things like Celebrex can be used in conjunction.
I know, you know, we don't load up on, on, on, you know, other ones,
but once we get them off the aspirin, they can go back on their anti-inflammatories.
And they use them at the same time. So I use, I send, I send people,
I use a lot of Tordol when people are in the hospital. I send them home a biloxicam.
(35:10):
And if people are on daily aspirins, I don't alter anything.
And actually, I use Xarelto if they're already on daily aspirin.
I let them use that, and I leave them the biloxicam.
And personally, I've not shown any bleeding problems with that.
I was just curious if you stop people's anti-inflammatories in the early time
after surgery while they're on their aspirin.
(35:30):
Yeah, we let them. I don't load them up too much, but we do let them.
I may not be as liberal as you with the Xarelto and plus that and all that.
But I think, again, I've not seen any major issues using them in combination.
And how about with other things, like if people are on aspirin and Plavix,
for example, or aspirin, I've had a couple of people that have been on aspirin
(35:52):
and even some of the other heavier anticoagulants.
Do you go ahead and just give them both if that's what they're on regularly anyway?
Do you restart their home medicines, I assume?
Yeah, I'm actually pretty or fairly aggressive. You might say I just start them
right back on their home dosing the day after surgery.
And again, in the rare patient that I use Xarelto or something,
(36:12):
I have some partners You might start them at half dose for a day or two,
but I just start them, restart them back because I do think if that person is
on a specific medication chronically for a valve or something,
they need to get back on that very quickly. It's also a discussion preoperatively.
And then some patients need to be on their anticoagulant, like a baby aspirin
right up until and during surgery for cardiac reasons.
(36:34):
I roll with that as well. I think, you know, between TXA and obviously good
surgical technique, I think we can mitigate a lot of the bleeding.
But again, I'm fairly aggressive on getting them back fairly quickly.
Last but not least, unless they have a mechanical valve or some other reason
they've been on it for years, can we relegate Coumadin to the trash bin of history where it belongs?
A little bit of PTSD or heartburn just thinking of all the Coumadin and getting
(36:57):
calls from the nurse in the middle of the night and trying to predict an iron ore level.
So if I can put that to bed, yes, I'd be a happy camper.
And again, it has really no role in my practice, but I don't want to speak ill
of those folks. So, again, it was our mainstay for a long time.
I hate warfarin, and I hope to never write the word warfarin on a chart for
(37:17):
the rest of my career. That'd be A-OK with me.
Well, as we wrap up here and kind of summarize your findings,
what are just a couple quick take-home points for our listeners before we wrap
up? Yeah, take on points.
You know, I think, you know, low-dose aspirin is highly effective in preventing,
mitigating DVT and PVT complications.
(37:39):
And it holds itself up in kind of head-to-head competition, so to speak,
with other anticoagulants, quote-unquote stronger ones on the market right now.
Now, so it has a really nice profile of doing what it says it does in terms
of preventing clots, but also not causing undue harm, bleeding complications
or other complications.
It's predictable in its dosing. It's cheap. It's cost effective.
(38:04):
And I think from my standpoint, this data and this paper further supports routine,
if not the default use of aspirin in total knee arthroplasty in 2024.
I think you convinced me. I've been on the fence about aspirin for a while after
reading this study in detail, talking with you tonight.
I think you converted me. So tomorrow morning, I'll go start the wheels turning
(38:30):
on changing that at our shop as well. So Dr.
Atul Kamath, thank you for joining us from the Cleveland Clinic to talk about
aspirin in VT prophylaxis at total knee.
Great topic, one that I think we can all learn from. And like I said,
I read a lot of big database studies like this that I'm then sad that I've I've
spent 20 minutes reading a study with a lot of statistical jargon and things
(38:51):
all to tell me that it didn't find anything,
that we don't have any more clarity than we had beforehand.
So this is one that I do think is clinically applicable.
And I thank you and your co-authors for doing it. And thanks for joining us.
Thanks a lot. I appreciate it. Now I got another podcast to subscribe to.
I'm excited to keep you guys along and you're doing great work.
And this was a great, fun session. Thanks so much.
(39:11):
I echo that exactly, those exact points. So, Dr. Kamen, thanks a lot for bringing
this topic and this great paper.
It was fun to read and definitely a fun discussion with you.
So, if you want to get a hold of us, you can reach us on Twitter and Instagram at the SKC Podcast.
You can visit our SKC Podcast YouTube and Facebook pages or email us at theskcpodcast
at gmail.com, and we will talk to you next time.
(39:35):
Music.
Music.
(00:11):
Of the Shelburne Knee Center Podcast. We're here with Scott Bauman,
my co-host tonight for another episode covering another jerk replacement and
knee replacement topic with another great guest.
So thank you for joining us. If you want to find us, you can find us wherever you get your podcasts.
You can find us on social media, on Twitter and Instagram, at the SKC Podcast.
We have a Facebook and YouTube page for the Shelburne Knee Center Podcast.
(00:33):
You can also email us if you'd like to ask us any questions or suggest any other
topics you'd like to hear about at the SKC podcast at gmail.com.
If you haven't, we highly recommend you go back to last week and listen to the episode.
We had a great guest on. We had Claudette Lejeune from NYU in New York City,
and we talked about something we really haven't discussed yet on the podcast,
a little bit different of a topic.
(00:54):
It was the ethical considerations of declining surgical intervention,
and it was really balancing the mix of the medical, legal, and financial implications
of taking care of patients in your orthopedic setting, especially with the high-risk population.
So, So if you haven't, before you listen to this episode, go back to last week's
episode and listen to Dr. Lejean discussing that topic.
(01:14):
If you heard that or any of our other topics and you'd like to leave us a five-star
review or a comment for those that come behind you, please do that as well.
Tonight, we're going to be talking about DBT prophylaxis, VTE prophylaxis, and joint replacement.
And this all comes from a JBJS article that is now in press.
Low-dose aspirin is the safest prophylaxis for prevention of venous thromboembolism
(01:36):
after total knee arthroplasty across all patient risk profiles.
And I know this is something that I haven't made the jump to yet and use an
aspirin as my DVT prophylaxis.
And I read this study with great interest to see whether it might change my mind.
So one of the authors from that manuscript is on the show tonight.
Dr. Atul Kamath is at the Cleveland Clinic in Cleveland, Ohio.
(01:58):
He went to medical school at Harvard Medical School, followed that up with a
residency in orthopedics at the University of Pennsylvania and a fellowship
in adult reconstruction at the Mayo Clinic.
He's the director of the Center for Hip Preservation at the Cleveland Clinic.
He's a professor of orthopedics at that institution, as well as Case Western Reserve University.
And he is a clinical innovation lead for Orthopedic and Rheumatologic Institute
(02:20):
at the Cleveland Clinic as well.
So, Dr. Atul Kamath, thank you for coming on with us tonight.
And we appreciate being able to have you on the show.
Thanks for having me. I'm excited to talk about this topic. and hopefully I
can convince you to switch to aspirin here.
Absolutely. So tell us about how you became interested in this topic.
What was your way into this specific topic from a research perspective?
(02:43):
Now, DVT prophylaxis, I think, is such an important topic, though,
just orthopedics in general.
And I think, obviously, joint replacement, given some of the higher risks with
patient population and the nature of the surgery, I think it's important to
kind of continuously look at DVT prophylaxis.
(03:04):
I do think over the last couple of decades, prophylaxis has come a long way just in general.
We're continuing to explore it, but I think looking at certain types of DVD
prophylaxis, such as Coumadin,
which had been highly used in orthopedics and joint replacements in the last
(03:25):
decade or so, in certain centers has fallen out of favor.
And then you look at other ones, novel anticoagulants that have really grown
in popularity in the cardiac space and other surgery spaces,
and then obviously have made their way into orthopedics.
So you have these different major trends. And throughout this time,
aspirin has been a choice of DVT prophylaxis.
(03:48):
And certainly from the standpoint the goal was
to understand temporal trends over time of using aspirin but
then kind of look at it you know versus maybe more
historical but then also specifically for this paper some
of the more newer anticoagulants and you know just really look at it specifically
in low and high risk populations so the topic being very complex the the basic
(04:12):
goal and the interest of our group was to look at the utility of using aspirin
And, you know, it's simple, it's cheap,
it's predictable, using it in low risk and high risk populations in joint replacement
and, and looking at that from that perspective.
So, you know, personal interest of mine was to see that because my practice,
and it probably sounds like it differs a little bit from yours is to use,
(04:34):
you know, aspirin is almost the default pathway.
And, and again, just taking it. So it's a personal interest to see how that fares.
And then also just broadly to see some of the trends in orthopedics and,
you know, not just safety for protection, but, you know, other things like complications
and hospital admissions and other sort of health systems type questions.
So a number of questions were kind of sparked by using this topic.
(04:56):
But again, that's sort of the overarching theme of
you know, why we wanted to tackle this particular. I have medical students with
me every month, and this is a topic that I try to cover every month with medical students,
just because it's kind of, it allows me to talk about a bunch of different things
that I want to talk about over the course of their month-long rotation with me all at the same time.
(05:16):
Obviously, I want to talk about risk factors and complications that can happen
from orthopedic surgery and just kind of general surgical principles of which
DVT prophylaxis is a really important one, especially with lower or extremity surgery.
I want to talk about the pharmacology of all these different agents.
So I'd have them look them up and then they tell me what they found.
And I see if I can remember if that's right or not before we move on to the next topic.
(05:40):
And just talking about the pluses and minus of each of those when they try to put it into practice.
I then put it on to them as a way to talk about research also is if you're going
to design a study for DVT prophylaxis, how would you design it?
And one of the reasons I like to talk about that is because this is not an easy
topic to study effectively and to get any good information out of for something
(06:03):
that is relatively uncommon.
Like venous thromboembolism after surgery, relatively speaking anyway,
and to have so many different agents that are possible, DVT prophylaxis agents
that you could study to design a well-done level one randomized controlled trial
with several different agents.
You would need thousands of patients to be able to show any statistically significant
(06:27):
and or clinically significant differences.
Just presents some challenges from a research perspective. So kind of give us
a little bit of background for what's out there.
And before you did this study, kind of what's out there that led you to say,
you know what, here's the way I think we can look at this problem differently
and hopefully answer this question.
Yeah, that's great. And I think, you know, what's exciting about your research
(06:50):
group is you're, you know, continuously looking at these topics.
And a podcast like this is a phenomenal way to kind of explore different topics.
But you're right, this is a huge, it's a complex topic.
And we took it from the perspective of can we use a large multi-center database?
I mean, this study, I don't know, I don't recall exactly, probably at least
(07:11):
60 centers were involved in the data that was called for this study.
But, you know, when we're talking about looking at a collaborative network that
includes almost 90 billion patients, I mean, this is a way we said,
listen, you know, we don't have the budget.
And also, you know, there's challenges to kind of do some sort of very large
scale prospective trial.
So we said, let's take a fairly thorough database, you know,
(07:33):
with enough power to do some propensity score matching and then,
you know, tease out those buckets, like I said.
So I think, you know, and hopefully we'll go into challenges of this particular
study design, but I do think there's challenges to anything,
but we thought, hey, let's use a large data set.
Let's try to tease that out and get enough patients in enough buckets to get
some meaningful answers.
I do think also there are some historical trials where a particular novel anticoagulant
(08:02):
or a particular DBT prophylaxis medicine was used in a level one prospective blinded trial.
But again, for me, sometimes those studies are just biased to looking at two
different medications or did not include an aspirin arm per se or just high-risk patients.
So we wanted to also be taking low-risk patients, high-risk patients,
(08:25):
taking patients on different medications.
And again, that for us required looking at a very large database.
I would also say that some of the studies, and again, there's conflicts of interest
with any particular study, but some of the studies historically have...
Been designed or developed by manufacturers or pharmaceutical companies.
So there's some inherent bias.
(08:47):
And again, well, you might say, hey, what's your bias? And I'm an orthopedic surgeon.
I don't have an interest in a particular pharmaceutical company.
However, my bias was that I use aspirin. I think one of the other co-authors,
Jay Parvizi, is also a heavy aspirin user.
And he's been a large proponent of aspirin for the last decade plus.
So you might say we have of, you know, at least two authors who come at this
(09:10):
study from an aspirin bias perspective.
And, you know, that may be an important thing to discuss as well.
You know, we do reference in the paper as well, the 2022 ICM or international
consensus meeting on BTE and for the audience and for the students and the trainees
and even surgeons out there who are not familiar with it,
I would say, take a look at that because that's sort of a global consensus meeting
(09:32):
that takes different topics,
including things like use of aspirin as a DVT prophylaxis measure and sort of
does a Delphi consensus structure to say, you know, is there best available evidence?
I would say one of the outputs of that did recommend aspirin as a VT,
as a very effective VT prophylaxis agent, including those in moderate and high risk groups.
(09:55):
So again, that, that sort of was a sort of of impetus to say,
hey, can we test that hypothesis or test that expert opinion,
consensus, review of the literature in another large scale population and go from there.
But again, that was a little bit of the study design and the purpose of using a large scale data set.
But again, I think worthwhile to just, as I said, highlight some of the either
(10:19):
personal or the sort of the perspective behind it.
I'm saying, well, let's see how good aspirin lines up against other measures. it's episode.
Now, you mentioned some trends towards aspirin and the international consensus
coming to that conclusion, as well as your own personal thoughts on this topic.
So, and I'm not sure how long you've been in practice, but is this something
that you have been utilizing for DVT prophylaxis, meaning aspirin,
(10:43):
or were there other agents that you were using that you had switched to after
diving into this topic more?
Yeah, so that's an excellent question. And I kind of alluded to a little bit
of my preamble because, you know, in, in the last decade of practice,
I've used predominantly aspirin, but I had used some Lovenox as well for,
(11:03):
for my joint replacements.
I had trained, and this is going back a little bit of time, but I had trained
at some institutions that, for example, in Philadelphia, where Buminin was a
standard for a lot of the joint replacements.
And I do recall, you know, as a trainee or, you know, resident,
you know, daily, you know, looking at iron levels, trying to titrate Cupid.
And again, of course, patients were in the hospital several days at that point,
(11:26):
but it was something where now a little bit, it's, you know,
aspirin's plug and play. I give it to them and I kind of like that convenience.
I always, I think, you know, another topic for discussion here,
and I always consider this and, you know, it's, it's not simply preventing DBT
as we're focusing on here, but it's also looking at things like bleeding complications
and looking at wound drainage.
(11:47):
So I always, and again, this is my perspective and my take was that aspirin
had a really nice profile of.
In my hands, and then, you know, certainly in talking with others,
it had a nice profile of preventing DVT, but then also had a nice profile as
well for minimizing complications such as bleeding, any sort of undue wound drainage.
(12:08):
And so, and then again, the ease of dosing, the ease of monitoring,
the ease looking at that from that perspective sort of was a happy medium from all perspectives.
But I do think, you know, again, bringing that to the table,
aspirin has been my predominant dvt prophylaxis measure for patients now if someone comes in.
You know on you know having a stent a year ago and they were on plavix plus
(12:31):
aspirin i mean i don't rock the boat too much on people who come in with specific
regimens for their you know cardiac medications or some other reason why they
would be on a different type of
anticoagulant so i will tend to keep those patients on those medications.
But again, someone who comes in naive off of a chronic anticoagulant,
(12:52):
I will use aspirin as the default rather than using something else.
So, and that's a little bit of my practice and that's been going on for a number of years. Yeah.
Yeah. Mine's kind of changed over time. When I first came into practice,
my partner was using was using Lovenox injections for three weeks at that time,
which is longer than I had experience with where we did it for two weeks in
(13:16):
residency and fellowship.
So I didn't want to be too disruptive. So I just kind of said,
okay, I'll roll with that.
There were some problems with it being expensive, some problems with people
not wanting to do the injections or not feel comfortable doing the injections, of course.
And then you have the occasional patient that bleeds and the first thing you
have to do is stop your anticoagulant. Then you're concerned that.
They're not protected from VTE, but we can't have them bleeding either and all
(13:40):
these issues that you bring up.
So that partner that I had subsequently went on to a different practice.
So I then switched back to two weeks, which everybody was happy about that we'd moved to two weeks.
And then after a while, people were just tired of the injections for the most
part. So I switched to Rivaroxaban over to Xarelto.
And in the last several years, that's been my agent of choice.
(14:02):
I've used aspirin very infrequently. I leave people on it if they're already
on it, but I haven't been using it for the DVT prophylaxis after surgery on
a routine basis or even on a risk stratified basis.
And my main concern was I just wondered, like a lot of us do,
whether or not there was the efficacy there for aspirin versus the,
you know, the other kind of, you know, kind of quote heavy hitter anticoagulants.
(14:24):
And it's just any time you take something back away when we're treating patients,
you You get concerned that, you know, if I have a complication,
you know, two weeks later, then I wonder if I just caused that trying to get
away from something that I wasn't really having a problem with.
So I've been watching closely as more and more data has come out about aspirin,
and I've tried to be kind of a slow adopter when it comes to this.
(14:47):
But, you know, I get a little bit of pressure from the hospital to decrease
costs by using aspirin. and I don't particularly like when my patients call
and say, hey, this costs a few hundred bucks that I don't really have to spend on this.
So that's where I'm really thinking about switching and I've just been waiting
for a couple more studies to come out and really for myself to look into it
(15:08):
enough to justify it to myself.
So let's dig into this study, if you don't mind, for the next several minutes
here and kind of talk about the specifics of this study.
So with that kind of as a background for the environment around VTE prophylaxis in joint replacement.
Tell us about the specific methods of your study and how you chose to evaluate this problem.
(15:28):
Yeah, so I think, you know, again, on the focus of we need some big data set
here, we use what's called the TrinetX collaborative network.
It has a number of centers, you know, and then again, probably close to 90 million
patients that are in this data set. that we decided to take a look at patients
(15:49):
receiving their total knee.
We wanted a broader timeframe, so we looked at 2012 to 2022.
And, and, and again, that was to try to see, we wanted to see trends over time
and then also try to look at, you know, rates of complications in a robust fashion.
We had, we took a look at patients at high risk for BTE and those were defined
as patients, you know, again,
(16:12):
through the international consensus meeting, these are patients who have,
you know, sort of different risk factors that would put them at higher risk,
including including things like obesity,
primary thrombophilia, things like history of stroke or COPD.
You know, there's a laundry list of things that might put someone at a higher
versus lower risk. And, you know, we really separate those.
(16:32):
After doing that, we probably had roughly close to about 50,000 patients in
each of those arms, you know, the high-risk arm and the low-risk arm.
And then with each of those arms, we try to take a look at the DVT prophylaxis.
So whether it was low-dose aspirin plus another anticoagulant,
which is the smaller groups in each one, then, you know, the majority of the
(16:54):
groups were either low-dose or the other sort of anticoagulant prophylaxis.
And these are the ones like, you know, the Warfarin's and the other ones you
mentioned as well, unfractionated heparin, the factor Xa inhibitors,
the direct thrombin inhibitors. So, you know, those were the other buckets.
And, you know, we did that for both the high-risk group and the low-risk group
and roughly probably about 20,000 patients in each of those arms of the,
(17:16):
you know, comparing the low-dose or the, you know, low-dose aspirin to the other anticoagulants.
And so those, you know, those were the ones where, you know,
we applied propensity score matching to kind of match them as well.
And some of your questions or thoughts from before, like there was looking at
characteristics such as chronic aspirin use and some other heart disease issues.
(17:38):
And so we really try to make sure that each of the buckets were comparable when
we did the propensity score matching.
And then again, you know, in terms of, you know, things like just curiosity,
we said, saying, well, what are their use of rates of aspirin versus other antipraglins in total need?
Over time. And, you know, there's a figure in the paper that you may recall that looks at,
(18:00):
you know, the increasing use of low-dose aspirin and then also,
you know, the decreasing trend over time from, you know, over the last decade
of the study, 2012 to 2022 of the other anticoagulants.
So a little bit of reflective, you know, now these are, are these just trends
in orthopedics? Is this something, but, you know, over that decade,
there was definitely a decrease in the the sort of bigger guns,
(18:22):
so to speak, of anticoagulants.
So it kind of reflected a little bit of what we had a sense of,
perhaps in the orthopedic field that, you know, there may be sort of a uptick in aspirin use.
As you know, the chest guidelines and things like that historically had been
not including aspirin, and then perhaps, you know, between the orthopedic community.
(18:44):
You know, using aspirin more or testing it out, plus some of the other guidelines
that were there. plus our academy.
I think, you know, some of those things, I think some of those forces definitely
were reflected in the fact that, you know, aspirin use both in low and high
dose aspirin use was increasing over time, specifically the low dose aspirin.
I think other kind of interesting things, if we look at it, you know,
(19:07):
the rates of DVT and P within the three months after,
DKA for all patients actually, you know, fell over time, you know,
in both DVT and P from that 2012 to 2022.
So I think it's something where the rates had come down as well.
Now, I think there's probably, and we bring this up in the discussion,
(19:28):
but is this because we're doing more rapid recovery protocols?
I don't think our patients are necessarily becoming healthier.
I think it may be a fact of probably more rapid mobilization,
probably better preoperative optimization, optimization.
But it was interesting as well, the rates of BVT and PE are overall falling.
Even in the sense in the light of now using a little bit more aspirin over time.
(19:52):
So, you know, we're not in that that specifically wasn't a conclusion that the
aspirin was the cause of this, I think it was more multifactorial.
I think it's the rapid recovery, the shorter length of stay,
the up and moving the day of surgery and all that.
So I think those were sort of more just observation type things.
And then, you know, kind of digging, you know, into the odds of actually using,
(20:13):
you know, prophylaxis, you know, even in higher risk patients,
we've found that, you know, their odds have been, you know, increasing over
time amongst even the higher risk groups.
So, you know, that was our kind of foundation, the kind of demographic propensity
matching, the temporal trends, and then also looking at the DVD trends.
Those set the stage a little bit for then specifically looking at odds ratios
(20:37):
for comparing aspirin to, you know, the other coagulants with respect to the
complication things that we were sort of discussing in the beginning. So.
Yeah, it's interesting that the same time that we're starting to shift away
from what we think are more significant anticoagulation,
we're also seeing a bit over the same time period, the appearance and the boom of tranexamic acid,
(20:59):
which all of us are worried we're going to cause DVTs when we first started using that.
So it's an interesting juxtaposition as we go to what we perceive as a little
bit lighter or of an anticoagulant, and we add a medicine that we are concerned could facilitate clot.
Formation, and the rates just keep going down, which is interesting.
(21:21):
And I think it's great information, something that I really commend the orthopedic
community for really studying in depth instead of just relying on,
you know, well, we think this is a worrisome, we think this isn't going to be efficacious enough,
you know, we're going to put it to the test with data and prove it.
And I think that's been a big improvement for all of us who do joint replacements.
(21:43):
Yeah. And I think even just not to get too much off topic, but,
you know, you bring up an excellent point about the transglaucoma acid.
I mean, it's sort of, it's been one of the game changers in joint replacement, right?
And orthopedics in the sense of, I mean, I may transfuse a patient once a year
or twice a year, and I do largely think it's probably due to transglaucoma acid, right?
I think we have better stewardship protocols, but again,
(22:06):
yeah, I mean, I always think back in designing this study, I thought back,
I did, you know, Mark Pagnano in the Mayo Clinic wrote a paper on,
and other groups have as well, on, you know, just using transedema acid,
even in high-risk patients, patients who've had cardiac histories,
and they found no really high risk of, you know, adverse events there.
(22:26):
Some of those, they found low risk of adverse events, because a lot of those
people were already on some higher level anticoagulants.
Yeah, and perhaps the bleeding control and all that. So I think whether to be
a rebel or not, or just mimic some of that spirit, it is a little bit of challenging
dogma and say, hey, you know, what is it about aspirin that may be good or not?
And again, I do think, you know, the rapid recovery protocols,
(22:49):
other things help us overall.
But I do think these trends and the efficacy that we're seeing here,
again, as best as controlled as we can, I think do still reign true or ring
true a little bit with aspirin being definitely a viable option, you know.
Dr. Kamath, I'm more of the numbers nerd around here, and hearing these methods
and reading this methodology, I thought it was great.
(23:11):
You're pulling from a system that you're measuring it by the millions is always
fascinating when you have these big data sets, and then you design a well-designed
study like you did where each arm of the study has nearly 20,000 patients.
So, first of all, great work on that, and I thought that was set up really well.
So, with all that being said, methodology-wise, can you tell us a little bit
about the main findings and the main takeaways from a results standpoint with this study?
(23:35):
Yeah. So, you know, the main results, you know, I think we talked a little bit
about, you know, the increase in the use of aspirin.
I think what was interesting and, you know, we did put together a number of
tables to try to compare, you know, different regimens like low-dose aspirin
versus the other anticoagulants.
We looked at low-dose aspirin versus rivaroxaban specifically.
(23:57):
And then also things like low-dose aspirin versus low-dose plus a combined anticoagulant.
So we tried to look at different combinations, and I would ask the readership
or the listenership to maybe dive into those tables to kind of look at the specific things.
But, you know, when we look at, you know, complications, so to speak,
(24:18):
we look at, you know, the main title was DVT and PE, but we looked at other
things like hemorrhage or hematoma or GI bleeding, even things like mortality, revision surgery,
ED visits, readmission.
So we try to look comprehensively for all those comparator groups.
And when we look at, for example, low-dose aspirin versus other anticoagulant,
(24:41):
the odds ratios were generally in favor of the low-dose aspirin groups.
I think there was maybe one where it was sort of a wash. I think it was,
for example, PJI was really no different between the two groups.
The confidence in Roll Cross won for that group. But every other parameter for
(25:01):
the low-dose versus other anticoagulants,
across the patient profiles were actually in favor of the low-dose aspirin,
some a little bit stronger.
Like for example, hemorrhage was more strongly in favor of the low-dose aspirin group.
And that gets to my comment before a little bit, you know, qualitatively,
(25:22):
I've always seen less wound complications, less bleeding at the surgical site
with using aspirin versus the other anticoagulants.
And then again, it's nice to see that you have an odds ratio of 0.25 or 0.23
three for things like DVT-PE.
So fairly protective on both ends of the spectrum.
And then other sort of other big, bad complications, mortality.
(25:43):
Stroke, things like that, MI really were in favor or certainly showed that aspirin
was effective in kind of mitigating those complications as well.
And again, this is in the first 90-day period, so fairly comprehensive.
It's not just in the the first two weeks or, you know, six weeks that we looked
at, we sort of took it out to the three-month period.
(26:04):
And then, like I said, you know, the listenership can kind of dig into the meat
of the other kind of comparator groups, including things like rivaroxaban only,
and then again, some of the other parameters.
So I do think, you know, there are within the limitations of trying to get as
many patients as possible.
And despite having tens of thousands of patients, I think you can always kind
(26:27):
of challenge your question.
And then even, I think there may be, you know, folks who may,
you know, look at our propensity matching or other parameters,
but, you know, again, like I said, the best we could do with the study available data points,
fairly robust study, and again, points that, you know, low-dose aspirin definitely performs well.
So I think that's sort of a major, you know, findings of the study,
(26:49):
you know, that, you know, both low-risk and high-risk patients in the low-dose aspirin group.
Had decreased odds of the bleeding, the complications, and even things like hospitalizations.
Yeah, I thought all those results were right on the money. The things I was
worrying about, people are going to get more DVTs? No.
People are going to get more PEs? No. Am I going to kill somebody if I use this
(27:10):
medicine instead of the other ones that I'm using?
Absolutely not. Do I need to risk stratify people? And it seems like the answer
is pretty convincingly no.
And then, of course, we can go down the line to the complications as well.
And even And those things are equal enough that we can start to assess cost as well.
I want to bring cost down like everybody else, but when somebody comes to me
(27:31):
leading with how does this cut cost,
I always respond with how is this beneficial to the patient before we start
thinking about how it benefits me or how we think about how it benefits the
healthcare system cost-wise.
And just across the board, the asthma performed in all categories as well as
causing less complications. So great paper.
(27:52):
And a lot of times when we get these big database studies,
one of my big frustrations with studies like this, to be honest with you,
is it's a lot of times when we do a lot of these big element studies with a
bazillion patients in all to find that there's no difference in anything and
that we haven't learned much.
So I was happy when I saw the results of this study and really reviewed them
(28:12):
closely in preparation for this to see that this is some really good information
that we can use in our practices.
So I guess I'll pin you down now and say yes or no.
Can we confidently say that aspirin is our preferred DVT prophylaxis agent in
all risk groups as a result of this study?
Yeah, I think, you know, from the standpoint, it goes back to a little bit of,
(28:34):
you know, we're creatures of habit too, right?
We like certain things, you know, and then again, you know, all it takes is
one patient to have a complication, a DVT or something that sometimes our emotional,
it sways our emotions on the next hundred patients may, you know,
may change our practice.
But I think sticking with this large database study that's well-controlled and
(28:54):
well-designed and really supports the use of aspirin, I would say that we can
definitely continue to support this. It doesn't mean this ends here.
I think it's worthwhile to study this, again, especially as we look at things
like rapid recovery, and then again, more complex and more comorbidities with our future patients.
These are all things to continuously look at this. So I don't think we rest
(29:17):
or I would say I rest on, okay, this is the be all end all in my practice.
I'll continue to to challenge this.
I do think there's other regional and other biases and other kind of understanding.
I will tell you that in response to this paper, a number of folks from around
the globe actually have written to me, and some have written letters to the editor,
some from Europe who do not use aspirin in certain countries and then don't
(29:40):
believe in it, and then some that are in support of it. Again,
so it's not just a US question, it's a global question.
But to the point of a very efficacious medication that has a great profile on
both ends of the spectrum, leading to clotting.
And then again, to your point about cost, if it's cheap, if it's readily dosed,
(30:00):
if it's now better understood and it's best for the patient as well as ease
on the health system, I think it's sort of a win-win.
So I would say that aspirin, you know, in my mind clearly has a strong role
and, you know, really should be given consideration as first-line therapy for
DVT prophylaxis and total knee replacements.
You made a good point about this not being just a U.S. problem.
(30:23):
It's more of a global problem, but bringing it back to the local nature to it.
I know you said you and I think you said Dr.
Parvisi was also using aspirin even prior to this study.
But, you know, I was looking at the author line. It looks like there's seven or eight authors there.
Have you talked to any of your co-authors or anybody within your own health
system that have since changed their prophylaxis to aspirin based on this study?
(30:45):
Yeah. So some of the coauthors, one is more on the statistical side.
But I would say just in general, our institution is a heavy aspirin use institution.
And we tried to standardize as well. We have a lot of surgeons.
We have a lot of thousands of joint replacements going on. So we try to standardize a lot of things.
But our general consensus is aspirin for primary and actually a number of the
(31:10):
revision surgeries as well.
And so again, we have certain parameters where we'll use the other anticoagulants,
but in general, the aspirin has become the default at our institution.
I do think in chatting at conferences, chatting with different surgeons here
and there in different venues, and then also in the spirit of putting this paper
together, I do think aspirin has become more widely accepted.
(31:33):
And again, I don't appreciate, Again, this is more anecdotal,
but in discussions with folks on the small scale, little conversations,
visiting a hospital or at a conference, they're experiencing the same beneficial
safety profiles that we're seeing here in the study.
So I do think, you know, a lot of folks have moved towards this.
And again, I'm a big advocate of it. I've always has been.
(31:55):
But I think this really supports that and at least opens the door for discussion
and at least opens the door for looking at our data and saying,
hey, does this does this ring true with my practice?
Does this is this an opportunity to understand this? And then again,
maybe start slowly with patients that you think may be the lowest risk of introducing
aspirin and not having complication, and then start building that up or working
(32:18):
that into more routine practice as your health system,
as you, as the patients get comfortable with this type of modality.
I'm going to go rapid fire at you with a few questions. And these,
these are going to be kind of short answer questions.
So we can cover a bunch of stuff in a short period of time, little nuance things.
Short one. Do you use this with TXA? I assume the answer is yes from our,
(32:39):
from our discussion so far.
Yeah. Standardized against a one gram on incision, one gram on closure.
And this is pretty much for everyone. Yeah. I think there's some rare contraindications
like color blindness or things like that.
I mean, I, but again, it's again, the default, everyone gets it.
But TXA and aspirin pretty much.
How about, how about bilaterals and revisions?
(33:00):
I tend to do very few bilateral simultaneous bilaterals. I'll tend to stage
them, but, but again, for, for closely staged.
And then again, some of my partners do a little bit more bilateral work.
We'll, we'll tend to use aspirin as well, or primaries for revisions.
You know, obviously, as you know, there's a whole spectrum of revision surgery.
(33:21):
You know, again, there's simple ones like the poly swap, so to speak,
versus the big, huge, massive cones and stems and things like that.
I tend to bias my use of Lovenox more in the more bigger surgeries.
And then again, more quote unquote simpler revisions, get aspirin 325 BID for six weeks.
(33:44):
For your standard patient cell, it's 81 milligrams twice a day. Is that correct?
Yes. And I, and I, you know, I use it for six weeks.
Now there are some in our group who do it as short as four weeks,
but that is something I think that was, you know, asked how's my practice changed
over time, but I have not changed the duration of using it, sort of starting it some time ago.
(34:06):
So I think, you know, probably can truncate it. Whereas I started 325 BAD for six weeks.
Years ago, I went down to 81 BID. I still kept it at six weeks now.
Perhaps maybe I could truncate it further or those who are running around a
clinic in two weeks, maybe I can even stop it then.
But that's just, again, my internal caution.
(34:27):
And again, as we dive into future studies,
maybe there's some way to very specifically look at that question.
Can we do it for two weeks and get them off? And I don't have that answer for
you today, but it would be interesting to say that. I just don't have the confidence
to say that with the available data. Yeah.
Rolling on with rapid fire questions and answers. Do you feel,
do you use this with anti-inflammatories in your post-op patients?
(34:49):
Yeah. Things like Celebrex can be used in conjunction.
I know, you know, we don't load up on, on, on, you know, other ones,
but once we get them off the aspirin, they can go back on their anti-inflammatories.
And they use them at the same time. So I use, I send, I send people,
I use a lot of Tordol when people are in the hospital. I send them home a biloxicam.
(35:10):
And if people are on daily aspirins, I don't alter anything.
And actually, I use Xarelto if they're already on daily aspirin.
I let them use that, and I leave them the biloxicam.
And personally, I've not shown any bleeding problems with that.
I was just curious if you stop people's anti-inflammatories in the early time
after surgery while they're on their aspirin.
(35:30):
Yeah, we let them. I don't load them up too much, but we do let them.
I may not be as liberal as you with the Xarelto and plus that and all that.
But I think, again, I've not seen any major issues using them in combination.
And how about with other things, like if people are on aspirin and Plavix,
for example, or aspirin, I've had a couple of people that have been on aspirin
(35:52):
and even some of the other heavier anticoagulants.
Do you go ahead and just give them both if that's what they're on regularly anyway?
Do you restart their home medicines, I assume?
Yeah, I'm actually pretty or fairly aggressive. You might say I just start them
right back on their home dosing the day after surgery.
And again, in the rare patient that I use Xarelto or something,
(36:12):
I have some partners You might start them at half dose for a day or two,
but I just start them, restart them back because I do think if that person is
on a specific medication chronically for a valve or something,
they need to get back on that very quickly. It's also a discussion preoperatively.
And then some patients need to be on their anticoagulant, like a baby aspirin
right up until and during surgery for cardiac reasons.
(36:34):
I roll with that as well. I think, you know, between TXA and obviously good
surgical technique, I think we can mitigate a lot of the bleeding.
But again, I'm fairly aggressive on getting them back fairly quickly.
Last but not least, unless they have a mechanical valve or some other reason
they've been on it for years, can we relegate Coumadin to the trash bin of history where it belongs?
A little bit of PTSD or heartburn just thinking of all the Coumadin and getting
(36:57):
calls from the nurse in the middle of the night and trying to predict an iron ore level.
So if I can put that to bed, yes, I'd be a happy camper.
And again, it has really no role in my practice, but I don't want to speak ill
of those folks. So, again, it was our mainstay for a long time.
I hate warfarin, and I hope to never write the word warfarin on a chart for
(37:17):
the rest of my career. That'd be A-OK with me.
Well, as we wrap up here and kind of summarize your findings,
what are just a couple quick take-home points for our listeners before we wrap
up? Yeah, take on points.
You know, I think, you know, low-dose aspirin is highly effective in preventing,
mitigating DVT and PVT complications.
(37:39):
And it holds itself up in kind of head-to-head competition, so to speak,
with other anticoagulants, quote-unquote stronger ones on the market right now.
Now, so it has a really nice profile of doing what it says it does in terms
of preventing clots, but also not causing undue harm, bleeding complications
or other complications.
It's predictable in its dosing. It's cheap. It's cost effective.
(38:04):
And I think from my standpoint, this data and this paper further supports routine,
if not the default use of aspirin in total knee arthroplasty in 2024.
I think you convinced me. I've been on the fence about aspirin for a while after
reading this study in detail, talking with you tonight.
I think you converted me. So tomorrow morning, I'll go start the wheels turning
(38:30):
on changing that at our shop as well. So Dr.
Atul Kamath, thank you for joining us from the Cleveland Clinic to talk about
aspirin in VT prophylaxis at total knee.
Great topic, one that I think we can all learn from. And like I said,
I read a lot of big database studies like this that I'm then sad that I've I've
spent 20 minutes reading a study with a lot of statistical jargon and things
(38:51):
all to tell me that it didn't find anything,
that we don't have any more clarity than we had beforehand.
So this is one that I do think is clinically applicable.
And I thank you and your co-authors for doing it. And thanks for joining us.
Thanks a lot. I appreciate it. Now I got another podcast to subscribe to.
I'm excited to keep you guys along and you're doing great work.
And this was a great, fun session. Thanks so much.
(39:11):
I echo that exactly, those exact points. So, Dr. Kamen, thanks a lot for bringing
this topic and this great paper.
It was fun to read and definitely a fun discussion with you.
So, if you want to get a hold of us, you can reach us on Twitter and Instagram at the SKC Podcast.
You can visit our SKC Podcast YouTube and Facebook pages or email us at theskcpodcast
at gmail.com, and we will talk to you next time.
(39:35):
Music.
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