New oral pharmacotherapeutic agents for venous thromboprophylaxis after total hip arthroplasty

Abstract

Patients undergoing total hip arthroplasty (THA) are at high risk for developing venous thromboembolism and, therefore, require short term prophylaxis with antithrombotic agents. Recently, target specific oral anticoagulants (TSOA) including the direct thrombin inhibitor, dabigatran, and the factor Ⅹa inhibitors rivaroxaban, apixaban, and edoxaban have been approved for THA thrombopropylaxis in various countries. The TSOAs provide a rapid acting, oral alternative to parenteral agents including low-molecular weight heparins (LMWH) and fondaparinux; and compared to warfarin, they do not require routine laboratory monitoring and possess much fewer drug-drug interactions. Based on phase Ⅲ clinical studies, TSOAs have established themselves as an effective and safe option for thromboprophylaxis after THA compared to LMWH, particularly enoxaparin, but require additional evaluation in specific populations such as the renally impaired or elderly. The ability to monitor and reverse these TSOAs in the case of bleeding complications or suspected sub-or supra-therapeutic anticoagulation is of importance, but remains investigational. This review will focus on the drug-specific characteristics, efficacy, safety, and economic impact of the TSOAs for thromboprophylaxis following THA, as well as the aspects of therapeutic monitoring and anticoagulation reversal in the event of bleeding complications or a need for urgent reversal. Key words: Oral; Thromboprophylaxis; Venous thromboembolism; Hip; Arthroplasty Core tip: This review focuses on the drug-specific characteristics, efficacy, safety, and economic impact of the target specific oral anticoagulants including dabigatran, rivaroxaban, apixaban, and edoxaban for thromboprophylaxis following total hip arthroplasty, as well as the aspects of therapeutic monitoring and anticoagulation reversal in the event of bleeding complications or a need for urgent reversal.Aikens GB, Osmundson JR, Rivey MP. New oral pharmacotherapeutic agents for venous thromboprophylaxis after total hip arthroplasty. World J Orthop 2014; 5(3): 188-203 Available from:

Clinical Benefits of Oral Anticoagulant Use in Cancer Patients at Increased Risk for Venous Thromboembolism per Khorana Index

“… 7 , 32 The preference of these agents, nonetheless, has declined due to major bleeding risk and adherence issues related to the inconvenient route of administration; several studies have thus far evaluated the thromboprophylactic effects of oral anticoagulants, both in cancer and non-cancer patients, as an alternative option to replace parenteral agents. 13–15 , 33 , 34 Two RCTs with the follow-up of 180 days demonstrated the efficacy of apixaban and rivaroxaban, respectively, along with an improved safety profile in terms of lower major bleeding risk in cancer patients as compared to placebo. 13 , 14 In consistent with these results, our study confirmed that NOACs significantly reduced thrombosis risks in terms of VTE as a whole and more specifically in DVT among cancer patients; bleeding risk was also assessed lower in those receiving NOACs relative to non-users.…”

Venous thromboembolism: identifying patients at risk and establishing prophylaxis

“…In addition, there are no methods for monitoring their anticoagulant effect. However, because the newer anticoagulants have a shorter half-life than warfarin or fondaparinux, antidotes may be less essential than with previous agents 140 and there have been recommendations in treatment guidelines as to how to effect reversal of these new agents if necessary 111,147-…”

Prognosis of Venous Thromboembolic Complications after Hip Replacement on the Background of Modern Thromboprophylaxis

“…This regimen of enoxaparin sodium was prescribed by the local protocol. In the postoperative period, the pharmacoprophylaxis of all patients was combined with elastic compression of the lower extremities and early activation [2,4,5]. Fibrinolysis inhibitors for the prevention of hemorrhagic complications were not used.…”

“…The use of some modern oral anticoagulants for VTEC prevention in this category of patients becomes more popular [5]. Nevertheless, the problem of venous thromboembolism in total HR is still relevant [5].…”