OBJECTIVES

Four previous meta-analysis compared enoxaparin with rivaroxaban for bleeding, deep vein thrombosis (DVT), pulmonary embolism (PE), and mortality outcomes. However, none of these studies included liver injury as an outcome. Some case reports and signal detection studies showed that enoxaparin was suspected of liver injury after arthroplasty. The objective of this study was to compare enoxaparin and rivaroxaban in their safety (liver injury and bleeding) and efficacy (DVT, PE, and mortality) by performing a meta-analysis of randomized controlled trials that focused in patients after total knee or hip arthroplasty.

METHODS

A comprehensive search was performed using PubMed, Embase, and Cochrane to retrieve studies that compared enoxaparin and rivaroxaban after arthroplasty. Relative risk (RR) and 95% confidence intervals using Mantel-haenszel approach were reported. Beta-Binomial model was applied to perform sensitivity analysis. The primary endpoints are liver injury and bleeding and the secondary endpoints are incidences of DVT, PE, and mortality.

RESULTS

Ten studies were included in the meta-analysis. Compared to rivaroxaban, enoxaparin had a higher risk of liver injury [RR= 1.77; 95% CI: 1.29,2.44]. Use of enoxaparin resulted in a nearly two-fold risk for DVT compared to rivaroxaban and was statistically significant. The pooled estimate for proximal DVT, distal DVT and any DVT were [RR=3.04; 95% CI: 1.34,6.88], [RR=1.72; 95% CI: 1.29,2.29], [RR=2.09; 95% CI :1.48,2.97] respectively. However, there was no statistically significant difference in the rate of symptomatic and asymptomatic DVT, PE, mortality, and bleeding between the two drugs.

CONCLUSIONS

Enoxaparin was associated with a higher risk for liver injury and rivaroxaban was associated with lower rates of distal DVT, proximal DVT, and any DVT. However, no difference was observed in the risk of bleeding, PE, and mortality. Overall, enoxaparin is less effective and more risky compared to rivaroxaban for people undergoing total knee or hip arthroplasty.