title: Relative effects of two different enoxaparin regimens as comparators against newer oral anticoagulants: meta-analysis and adjusted indirect comparison.
abstract: BACKGROUND
  Two different regimens of enoxaparin (40 mg once daily or 30 mg bid) have been used as control arms in trials of new oral anticoagulants. The choice of enoxaparin comparator may influence the perceived relative efficacy and safety of the newer agents, and we aimed to identify any significant differences between the two enoxaparin regimens.
  
  
  METHODS
  We searched MEDLINE, EMBASE, and Cochrane Library for randomized controlled trials that compared enoxaparin to oral anticoagulant (apixaban, dabigatran, rivaroxaban) thromboprophylaxis in elective total knee or hip arthroplasty. Total VTE and bleeding events were pooled using fixed-effects meta-analysis and heterogeneity assessed with the I2 statistic. We conducted adjusted indirect comparisons of bid vs once-daily enoxaparin regimes based on new oral anticoagulants as common comparators.
  
  
  RESULTS
  Fourteen randomized controlled trials in hip and knee replacement surgery met the inclusion criteria. Adjusted indirect comparison showed that bid enoxaparin was significantly more effective in preventing VTE than enoxaparin once daily (relative risk [RR], 0.71; 95% CI, 0.61-0.83; P &lt; .00001). For major and clinically relevant hemorrhage, adjusted indirect comparison showed that enoxaparin bid was nonsignificantly associated with increased risk of bleeding (RR 1.27; 95% CI, 0.97-1.65; P = .08) above that of enoxaparin once daily. Subgroup analysis limited to total knee arthroplasty trials showed similar results.
  
  
  CONCLUSIONS
  The use of once-daily enoxaparin regimen as control in clinical trials will lead to more favorable estimates of relative efficacy for the new oral anticoagulants than if enoxaparin 30 mg bid had been chosen as a comparator.
authors.affiliation: Medical Division, Norfolk and Norwich University Hospitals National Health Service Foundation Trust, Norfolk, England; Population Health Group, Norwich Medical School, University of East Anglia, Norfolk, England.
authors.forename: Chun Shing
authors.initials: CS
authors.lastname: Kwok
authors.affiliation: Department of Medicine, James Paget University Hospitals NHS Foundation Trust, Norfolk, England.
authors.forename: Shiva
authors.initials: S
authors.lastname: Pradhan
authors.affiliation: Medical Division, Norfolk and Norwich University Hospitals National Health Service Foundation Trust, Norfolk, England; Population Health Group, Norwich Medical School, University of East Anglia, Norfolk, England.
authors.forename: Jessica Ka-Yan
authors.initials: JK
authors.lastname: Yeong
authors.affiliation: Medical Division, Norfolk and Norwich University Hospitals National Health Service Foundation Trust, Norfolk, England; Population Health Group, Norwich Medical School, University of East Anglia, Norfolk, England. Electronic address: y.loke@uea.ac.uk.
authors.forename: Yoon K
authors.initials: YK
authors.lastname: Loke
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage*; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D001562:Benzimidazoles / Q000008:administration & dosage; D000069604:Dabigatran; D017984:Enoxaparin / Q000008:administration & dosage*; D006801:Humans; D009025:Morpholines / Q000008:administration & dosage; D011720:Pyrazoles / Q000008:administration & dosage; D011728:Pyridones / Q000008:administration & dosage; D016032:Randomized Controlled Trials as Topic; D000069552:Rivaroxaban; D013876:Thiophenes / Q000008:administration & dosage; D054556:Venous Thromboembolism / Q000517:prevention & control*; D015091:beta-Alanine / Q000008:administration & dosage / Q000031:analogs & derivatives
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D017984:Enoxaparin; D009025:Morpholines; D011720:Pyrazoles; D011728:Pyridones; D013876:Thiophenes; D015091:beta-Alanine; C522181:apixaban; D000069552:Rivaroxaban; D000069604:Dabigatran