Reversal of direct oral anticoagulants in adult hip fracture patients. A systematic review and meta-analysis |
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| Institution: | 1. Academic Clinical Fellow, Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham, UK;2. Trauma and Orthopaedic Surgical Registrar, Centre for Trauma Sciences, Blizzard Institute, Queen Mary University of London, UK;3. Professor and Consultant Anaesthetist, Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham, UK Department of Anaesthesia, Nottingham University Hospitals, UK;1. University of Bari “Aldo Moro”. Department of Basic Medical Sciences, Neuroscience and Sense Organs. Orthopaedic and Trauma Unit, Piazza Giulio Cesare, 11. 70124. Bari, Italy;2. Orthopaedic and Trauma Unit, Humanitas Research Hospital, Milano, Italy;1. Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China;2. Department of Traumatology, Surgical Division, University Medical Centre, Ljubljana, Slovenia;1. Department of Orthopedic Surgery, Maxima Medical Center, Eindhoven, the Netherlands;2. Southmead Hospital North Bristol NHS Trust Bristol, United Kingdom BS10 5NB;3. 0490 McCaig Tower, Foothills Medical Center 3134 Hospital Dr NW Calgary, Alberta, Canada T2N 5A1;1. Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, 6 Jiefang Street, Dalian, Liaoning 116001, China;2. Department of Orthopaedics, Yantai Hospital of Shandong Wendeng Orthrpaedics & Traumatology, Shanhai South Road, Laishan district, Yantai 264003, Shandong Province, China;1. Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan;2. Department of Orthopaedic Surgery, Saga Prefectural Hospital Koseikan, 400, Ohaza Nakabaru, Kase-Town, Saga, Japan;3. Department of Orthopaedic Surgery, Fukuoka Orthopaedic Hospital, 2-10-50 Yanagouchi, Minami-ku, Fukuoka, Japan;4. Department of Anatomic Pathology, Graduate School of Medical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan;5. Department of Orthopaedic Surgery, Kyushu Rosai Hospital, 1-1 Sone north town, Kokura Minami-ku, Kitakyushu city, Japan;6. Department of Orthopaedic Surgery, Iizuka Hospital, 3-83 Yoshio town, Iizuka city, Fukuoka, Japan;7. Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, 3-23-1 Shiobaru, Minami-ku, Fukuoka, Japan;8. Department of Orthopaedic Surgery, Japan Community Healthcare Organization Kyushu Hospital, 1-8-1 Kishinoura, Yahata Nishi-ku, Kitakyushu, Japan;9. Department of Orthopaedic Surgery, Fukuoka City Hospital, 13-1 Yoshizukamotomachi, Hakata-ku, Fukuoka, Japan;10. Department of Orthopaedic Surgery, Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-ku, Fukuoka, Japan;11. Department of Orthopaedic Surgery, Shimonoseki City Hospital, 1-13-1 Kouyouchou, Shimonoseki, Yamaguchi, Japan;12. Department of Orthopaedic Surgery, Miyazaki Prefectual Miyazaki Hospital, 5-30 Kitatakamatsu town, Miyazaki, Japan;13. Department of Orthopaedic Surgery, National Hospital Organization Fukuoka-higashi Medical Center, 1-1-1 Chidori, Koga city, Fukuoka, Japan |
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| Abstract: | BackgroundIncreasing numbers of patients are taking Direct Oral Anticoagulants at the time of hip fracture. Evidence is limited on how and if the effects of DOAC's should be reversed before surgical fixation. Wide variations in practice exist. We conducted a systematic review to investigate outcomes for three reversal strategies. These were: “watch and wait” (also referred to as “time-reversal”), plasma product reversal and reversal with specific antidotes.MethodsA systematic search was conducted using multiple databases. Results were obtained for studies directly comparing different DOAC reversal strategies in hip fracture patients and for studies comparing DOAC-taking hip fracture patients (including patients “reversed” using any method and “non-reversed” patients) against matched controls taking either a vitamin-K antagonist or not receiving anticoagulation therapy. This allowed construction of a network meta-analysis to indirectly compare outcomes between “reversed” and “non-reversed” DOAC patients. With respect to “watch and wait”/“time-reversal”, a cut-off time to surgery of 36 hours was used to distinguish between “time-reversed” and “non time-reversed” DOAC patients. The primary outcome was early/inpatient mortality, reported as Odds Ratios (OR).ResultsNo studies investigating plasma products or reversal agents specifically in hip fracture patients were obtained. Fourteen studies were suitable for analysis of “watch and wait”/“time- reversal”. Two studies directly compared “time-reversed” and “non time-reversed” DOAC-taking hip fracture patients (58 “time-reversed”, 62 “non time-reversed”). From 12 other studies we used indirect comparisons between “time-reversed” and “non time-reversed” DOAC patients (total, 357 “time-reversed”, 282 “non time-reversed”). We found no statistically significant differences in mortality outcomes between “time-reversal” and “non time-reversal” (OR 1.48 95%CI: 0.29-7.53]). We also did not find a statistically significant difference between “time reversal” and “non time-reversal” in terms of blood transfusion requirements (OR 1.16 95% CI 0.42-3.23]). However, several authors described that surgical delay is associated with worse outcomes related to prolonged hospitalisation, and that operating within 36 hours is safe.ConclusionsWe suggested against “watch and wait” to reverse the DOAC effect in hip fractures. Further work is required to assess the optimal timing for surgery as well as the use of plasma products or specific antidotes in DOAC-taking hip fracture patients. |
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