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Benefits of Novel Oral Anticoagulant Agents for Thromboprophylaxis after Total Hip or Knee Arthroplasty Richard J. Friedman, MD, FRCSC Background: The incidence of venous thromboembolism (VTE) after total hip arthroplasty (THA) or total knee arthroplasty (TKA) is reduced by the use of thromboprophylactics, such as vitamin K antagonists, low-molecular-weight heparin (LMWH), or fondaparinux. However, these agents have a number of limitations that constrain their use and increase the clinical and economic burden on patients, caregivers, and healthcare resources. Effective prophylaxis may also be complicated by poor adherence to guideline recommendations. Objective: This article reviews the potential of newly developed oral anticoagulants to address many of the management challenges associated with vitamin K antagonists, LMWHs, and fondaparinux. Discussion: The 3 oral anticoagulants rivaroxaban, apixaban, and dabigatran have been evaluated in large phase 3 trials, and all 3 represent promising alternatives to the current standard of care. Currently, rivaroxaban is the only new oral agent to have received US Food and Drug Administration approval in the United States for prophylaxis of deep-vein thrombosis, which may lead to pulmonary embolism in patients undergoing THA or TKA. The simplified management of the new oral agents may encourage adherence with published guidelines for VTE prophylaxis and help to reduce the economic burden of VTE. Pharmacoeconomic data suggest that rivaroxaban and dabigatran may result in cost-savings when compared with enoxaparin after THA or TKA. Conclusions: The numbers of THA and TKA surgeries are expected to increase significantly in coming years, and safer and more effective thromboprophylaxis is essential to mitigate the morbidity and mortality associated with VTE. Newly developed oral anticoagulants have the potential to address many of the limitations of current thromboprophylaxis and may reduce the cost burden associated with the management of VTE after THA or TKA.
T
otal hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most common orthopedic procedures performed in the United States, with almost 300,000 THA surgeries and more than 500,000 TKA surgeries performed annually.1 This number is projected to rise to approximately 572,000 annual THA surgeries and 3.5 million annual TKA surgeries by 2030.1 THA and TKA procedures improve mobility and quality of life, but patients undergoing these surgeries are at a significantly increased risk for developing postoper-
Dr Friedman is Chairman, Department of Orthopaedic Surgery, Roper Hospital; Clinical Professor of Orthopaedic Surgery, Medical University of South Carolina, Charleston; and Medical Director of Charleston Orthopaedic Associates.
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ative venous thromboembolism (VTE).2-4 VTE comprises both deep-vein thrombosis (DVT) and pulmonary embolism (PE). In the absence of thromboprophylaxis, proximal DVT occurs in approximately 5% to 36% of patients who have THA and TKA.5 PE occurs in 50% of patients with proximal DVT,4 and proves fatal in approximately 15% of these patients.6 VTE is also associated with significant long-term complications, such as postthrombotic syndrome, chronic thromboembolic pulmonary hypertension, and an increased risk of recurrent events.7 Postthrombotic syndrome develops in 23% to 60% of patients, often in the 2 years after a DVT, and approximately 10% of cases are considered to be severe.8 Approximately 4% of patients with PE are diagnosed with chronic thromboembolic pulmonary hypertension within 2 years9; approximately
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KEY POINTS ➤
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➤
➤
➤
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THA and TKA are common orthopedic procedures that improve a patient’s quality of life but are associated with a significant risk for postoperative VTE and long-term complications. The incidence of VTE can be effectively reduced with thromboprophylactics, including vitamin K antagonists, LMWHs, or fondaparinux. However, these agents are associated with management challenges that limit their use and increase the clinical and economic burden on patients, caregivers, and the US healthcare overall. Currently, 3 new oral anticoagulants are in different stages of development—rivaroxaban, apixaban, and dabigatran—with the first agent recently receiving FDA approval in the United States. The new oral anticoagulants offer several benefits over current thromboprophylactics, including fixed dosing thanks to their predictable pharmacokinetics, no requirement for coagulation monitoring, few drug–drug and drug–food interactions, and once-daily or twice-daily oral administration. When considering the best thromboprophylactic agent, the associated costs related to anticoagulation need to be taken into account, including costs for drug acquisition, mode of administration, and routine coagulation monitoring.
10% of patients who experience VTE after THA or TKA are readmitted to the hospital within 3 months after discharge.10 The incidence of VTE can be effectively reduced with the use of thromboprophylactics, including vitamin K antagonists, low-molecular-weight heparins (LMWHs), or fondaparinux (Arixtra). Thromboprophylaxis reduces the cumulative incidence of symptomatic VTE to 1.7% within 3 months of THA and to 2.3% within 3 months of TKA.11 However, these agents pose a number of management challenges that limit their use and increase the clinical and economic burden on patients, caregivers, and healthcare resources. Effective prophylaxis may also be complicated by poor adherence to guideline recommendations, possibly resulting from physicians’ concern about the risk for bleeding or the difficulties of maintaining prophylaxis in an outpatient setting. Newly developed oral anticoagulants have the potential to address many of the limitations associated with vitamin K antagonists, LMWHs, and fondaparinux. They may also simplify treatment strategies for these patients, encourage compliance with therapy, and reduce the economic burden of VTE.
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The Economic Burden of VTE The costs of managing acute and chronic VTE are considerable, particularly those associated with hospitalization, long-term therapy, and monitoring.12,13 In the United States, management of VTE costs almost $500 million annually.13 A study using data from a large healthcare claims database showed that for patients with in-hospital VTE, mean billed charges were $18,834 higher than for matched controls (ie, individuals of the same age who underwent the same procedure but had no claim for DVT or PE); the increment was $7351 in TKA patients and $27,034 in THA patients.10 Another analysis of the economic burden of VTE in hospitalized patients estimated the cost of managing an initial episode of DVT to be between $7712 and $10,804, and between $9566 and $16,644 for an initial PE event.14 Long-term complications of VTE, such as recurrent VTE, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension, add to the cost of treatment.15-17 The cost of hospital readmission for a recurrent DVT is estimated to be 21% greater than the cost for the initial DVT event, mainly because of the longer hospital stay.16 The long-term costs of treating postthrombotic syndrome are estimated to add 75% to the cost of treating the initial DVT.17 The considerable morbidity associated with chronic thromboembolic pulmonary hypertension also adds to costs. The direct cost of managing patients with chronic thromboembolic pulmonary hypertension has been estimated to be $4782 per patient per month (PPPM) versus $511 PPPM for controls, with circulatoryrespiratory–related costs accounting for 55% of the excess costs.18 Although thromboprophylaxis reduces the incidence of VTE and its associated costs, the costs associated with anticoagulation need to be considered, including those for drug acquisition, administration, and routine coagulation monitoring. In addition, because the use of anticoagulants may increase the risk for bleeding, the cost of bleeding management should be taken into consideration. A recent analysis of insurance healthcare claims found that the monthly incremental costs per patient are similar for the management of VTE and bleeding events ($2729 and $2696, respectively) in patients with major orthopedic surgery.19 However, the overall 3month risk for bleeding was substantially lower than the risk for VTE.19 Barriers to Optimal Thromboprophylaxis Although thromboprophylaxis can effectively reduce the incidence of VTE in patients undergoing THA or TKA, barriers to optimal thromboprophylaxis exist.
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These barriers include: • Poor implementation of guidelines • Bleeding concerns • Limitations of existing agents.
Poor Implementation of Guidelines for the Prevention of VTE Clinical practice guidelines for the prevention of VTE have been published by the American College of Chest Physicians (ACCP) every 3 years for more than 20 years.3,20 The most up-to-date version of these guidelines recommends the routine use of traditional anticoagulants—LMWHs, fondaparinux, vitamin K antagonists (ie, warfarin)—aspirin, or one of the new oral anticoagulants—rivaroxaban (Xarelto), dabigatran (Pradaxa), or apixaban (Eliquis)—for pharmacologic thromboprophylaxis in individuals who have undergone THA or TKA surgery.3 The American Academy of Orthopaedic Surgeons (AAOS) recently published updated guidelines for the prevention of VTE in patients undergoing THA or TKA.21 The AAOS recommends the use of mechanical compression devices in appropriate patients, in addition to pharmacologic agents.21 Retrospective analyses of data collected by the Global Orthopaedic Registry (GLORY) between June 2001 and December 2004 have demonstrated limited adherence to guidelines for VTE prophylaxis in the United States, with room for much improvement.22,23 One barrier to the implementation of guidelines in the United States may be the considerably shorter period of time that patients undergoing THA or TKA spend in the hospital compared with other countries. In the United States, median lengths of hospital stay are only 3 and 4 days for THA or TKA, respectively, and it is likely that the duration of prophylaxis recommended by the ACCP (10-35 days) is difficult to achieve in an outpatient setting.3,22 A retrospective cohort study has also showed that physicians often use lower-than-recommended doses of LMWH, inadequate bridging protocols when switching from injectable agents to warfarin (which takes 3-5 days to reach effective levels), and insufficient or no therapy after hospital discharge.24 Concerns about Bleeding Although the major complication of all anticoagulant therapy is bleeding, when thromboprophylaxis is administered postsurgically to patients undergoing THA or TKA, the rates of major bleeding events are low. Major bleeding with LMWH prophylaxis after THA or TKA is estimated to be between 3% and 5%.25 Major bleeding with warfarin use is also low (approximately 4% at a target international normalized ratio of 2.0) and is heavily
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dependent on the patient’s predisposing risk factors, such as comorbid conditions (eg, cancer, hypertension, heart disease, cerebrovascular disease, renal insufficiency, and paraplegia).25 Patient characteristics (eg, age and a history of bleeding), concomitant medications, and incorrect timing and/or dosing of the anticoagulant also contribute to bleeding risk.25 For example, a patient aged >75 years who weighs >50 kg and has compromised renal function is at an increased risk for a major bleeding event. Complications may be avoided by taking a highly conservative approach to anticoagulation in these individuals; therefore, the risk for bleeding with appropriate use of thromboprophylactics may be overestimated.26,27
Limitations of Current Agents Existing anticoagulants carry a number of limitations that contribute to suboptimal thromboprophylaxis in patients undergoing THA or TKA. LMWHs and fondaparinux are inconvenient, particularly in the outpatient setting, because they are administered parenterally, and their use may accrue significant costs related to home administration by nurses, patient training, and monitoring. In addition, all heparins, including LMWHs, carry the risk for heparin-induced thrombocytopenia, and long-term therapy is associated with osteoporosis.28 Orally administered warfarin has complex pharmacokinetic and pharmacodynamic properties and a narrow therapeutic window, making routine coagulation monitoring and dose adjustments essential.28,29 Warfarin also has a slow onset and offset of action, which means that patients already receiving warfarin may need to adhere to complicated perioperative bridging protocols. In addition, warfarin has multiple food and drug interactions, and its metabolism is susceptible to numerous genetic polymorphisms.28,29 The New Oral Anticoagulants Three new oral anticoagulants have undergone phase 3 clinical studies in patients undergoing THA or TKA in the United States (Table).30-40 Two of these agents— rivaroxaban and apixaban—are factor Xa inhibitors, whereas dabigatran is a direct thrombin inhibitor. The beneficial characteristics of these 3 new anticoagulants include41: • Fixed dosing as a result of their predictable pharmacokinetics • No requirement for coagulation monitoring • Few drug–drug and drug–food interactions • Once- or twice-daily oral administration. Rivaroxaban Rivaroxaban selectively blocks the active site of factor
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Table Phase 3 Clinical Trials of Rivaroxaban, Apixaban, and Dabigatran Prophylaxis after Total Hip or Knee Arthroplasty
Drug
Surgery
Study
Subcutaneous enoxaparin dose
Oral drug dose
RECORD1 (2008)30
31-39
RECORD2 (2008)31
Rivaroxaban: 31-39 Enoxaparin: 10-14
THA 40 mg once daily
Rivaroxaban TKA
TKA Apixaban THA
RECORD4 (2009)33
30 mg twice daily
ADVANCE-1 (2009)34
30 mg twice daily
40 mg once daily
ADVANCE-3 (2010)36
150 mg or 220 mg once daily 40 mg once daily
RE-MODEL (2007)39 RE-MOBILIZE (2009)40
2.5 mg twice daily 32-38
RE-NOVATE II (2011)38
30 mg twice daily
Primary efficacy outcome
Efficacy of study drug vs enoxaparin
Composite of any DVT, nonfatal PE, and death
Superior
10-14
10-14
ADVANCE-2 (2010)35
THA
TKA
10 mg once daily
RECORD3 (2008)32
RE-NOVATE (2007)37
Dabigatran
Duration, days
Did not meet noninferiority Superior Superior
28-35
220 mg once daily 150 mg or 220 mg once daily
Composite of symptomatic or asymptomatic DVT, nonfatal PE, and death
Composite of total VTE events and death
Noninferior a
6-10 12-15
Did not meet noninferiority
a
Dabigatran was superior to enoxaparin for reducing the risk of major VTE (secondary end point) in the RE-NOVATE II study. DVT indicates deep-vein thrombosis; PE, pulmonary embolism; THA, total hip arthroplasty; TKA, total knee arthroplasty; VTE, venous thromboembolism.
Xa and does not require a cofactor (such as antithrombin) for activity. Because rivaroxaban has predictable pharmacokinetic and pharmacodynamic properties and a low potential for interactions with food or other drugs, it can be administered as a fixed dose, without the requirement for routine coagulation monitoring.42 A large phase 3 investigative program composed of 4 clinical trials that compared rivaroxaban with enoxaparin (Lovenox) in patients undergoing THA or TKA— Regulation of Coagulation in Orthopaedic Surgery to Prevent Deep Vein Thrombosis and Pulmonary Embolism (RECORD)—has been completed.42 The pri-
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mary efficacy end point of the 4 RECORD studies was total VTE—the composite of any DVT, nonfatal PE, and all-cause mortality (Table).30-33 The RECORD1 trial demonstrated that rivaroxaban 10 mg once daily was superior to enoxaparin 40 mg once daily for 30 to 35 days after THA,30 whereas the RECORD2 study demonstrated the superiority of longterm thromboprophylaxis with rivaroxaban 10 mg once daily (31-39 days) versus short-term thromboprophylaxis with enoxaparin 40 mg once daily (10-14 days) in patients undergoing THA.31 The RECORD3 and RECORD4 studies demonstrated the superior efficacy
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of rivaroxaban 10 mg once daily versus enoxaparin 40 mg once daily and 30 mg twice daily (a regimen approved in North America after TKA), respectively, for 10 to 14 days after TKA.32,33 In a pooled analysis of the RECORD studies, rivaroxaban significantly reduced the composite of symptomatic VTE and all-cause mortality versus enoxaparin and was associated with a similar safety profile.43 In July 2011, rivaroxaban became the first new oral agent to be approved by the US Food and Drug Administration (FDA) in the United States for prophylaxis of DVT (which may lead to PE) in patients undergoing THA or TKA, based on results from the RECORD1, 2, and 3 trials. The Centers for Medicare & Medicaid Services has issued a memo that rivaroxaban administration after THA and TKA is Surgical Care Improvement Project–compliant as of July 2, 2011.
Apixaban Another oral, direct factor Xa inhibitor, apixaban, has also been studied in phase 3 trials in patients undergoing THA or TKA (Table).34-36 Apixaban is currently approved for the prevention of VTE after THA or TKA in the European Union. In the Apixaban Versus Enoxaparin for Thromboprophylaxis After Knee Replacement (ADVANCE)-1 trial, apixaban 2.5 mg twice daily was compared with enoxaparin 30 mg twice daily in patients post-TKA. However, apixaban did not meet the prespecified statistical criteria for noninferiority for the composite primary efficacy end point of asymptomatic and symptomatic DVT, nonfatal PE, and death from any cause during treatment.34 In the ADVANCE-2 and ADVANCE-3 trials, apixaban 2.5 mg twice daily was compared with enoxaparin 40 mg once daily and demonstrated superior efficacy in patients who had undergone TKA (ADVANCE-2) and THA (ADVANCE-3).35,36 Apixaban compared with enoxaparin was not associated with an increase in bleeding events in any of the 3 ADVANCE studies.34-36 Dabigatran Dabigatran etexilate is an oral direct thrombin inhibitor that has a low potential for drug–drug interactions and a predictable anticoagulant effect.44 Dabigatran is approved for VTE prophylaxis after THA/TKA surgery in Canada and the European Union, but not currently in the United States. Dabigatran 150 mg or 220 mg once daily demonstrated noninferiority to enoxaparin 40 mg once daily for 28 to 35 days after THA in the RE-NOVATE and RENOVATE II studies, and for 6 to 10 days after TKA in the RE-MODEL study (Table).37-39 In the RE-MOBILIZE study (TKA), dabigatran failed to meet the noninferior-
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ity criteria when compared with enoxaparin 30 mg twice daily.40 Dabigatran had a similar safety profile versus enoxaparin in all 4 studies.37-40
Limitations of the New Oral Anticoagulants Despite their important advantages―oral administration, a rapid onset and offset of action, predictable pharmacokinetics that allow fixed dosing, no requirement for coagulation monitoring, and significantly fewer food–drug and drug–drug interactions than warfarin―the new oral anticoagulants also have some limitations. Although to date rivaroxaban is the only anticoagulant approved in the United States for use in orthopedic patients, efficacy and safety data from phase 3 clinical trials facilitate assessment of the limitations of dabigatran and apixaban as well. Renal function is very important for dabigatran; 80% is renally excreted, with the remainder excreted via the bile.44,45 There has been recent concern regarding excess bleeding in patients receiving dabigatran. These reports are currently being investigated by the FDA. The rivaroxaban dose must be adjusted in patients with renal insufficiency, and its use should be avoided in patients with severe renal impairment (creatinine clearance
CLINICAL
REVIEW ARTICLE
Benefits of Novel Oral Anticoagulant Agents for Thromboprophylaxis after Total Hip or Knee Arthroplasty Richard J. Friedman, MD, FRCSC Background: The incidence of venous thromboembolism (VTE) after total hip arthroplasty (THA) or total knee arthroplasty (TKA) is reduced by the use of thromboprophylactics, such as vitamin K antagonists, low-molecular-weight heparin (LMWH), or fondaparinux. However, these agents have a number of limitations that constrain their use and increase the clinical and economic burden on patients, caregivers, and healthcare resources. Effective prophylaxis may also be complicated by poor adherence to guideline recommendations. Objective: This article reviews the potential of newly developed oral anticoagulants to address many of the management challenges associated with vitamin K antagonists, LMWHs, and fondaparinux. Discussion: The 3 oral anticoagulants rivaroxaban, apixaban, and dabigatran have been evaluated in large phase 3 trials, and all 3 represent promising alternatives to the current standard of care. Currently, rivaroxaban is the only new oral agent to have received US Food and Drug Administration approval in the United States for prophylaxis of deep-vein thrombosis, which may lead to pulmonary embolism in patients undergoing THA or TKA. The simplified management of the new oral agents may encourage adherence with published guidelines for VTE prophylaxis and help to reduce the economic burden of VTE. Pharmacoeconomic data suggest that rivaroxaban and dabigatran may result in cost-savings when compared with enoxaparin after THA or TKA. Conclusions: The numbers of THA and TKA surgeries are expected to increase significantly in coming years, and safer and more effective thromboprophylaxis is essential to mitigate the morbidity and mortality associated with VTE. Newly developed oral anticoagulants have the potential to address many of the limitations of current thromboprophylaxis and may reduce the cost burden associated with the management of VTE after THA or TKA.
T
otal hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most common orthopedic procedures performed in the United States, with almost 300,000 THA surgeries and more than 500,000 TKA surgeries performed annually.1 This number is projected to rise to approximately 572,000 annual THA surgeries and 3.5 million annual TKA surgeries by 2030.1 THA and TKA procedures improve mobility and quality of life, but patients undergoing these surgeries are at a significantly increased risk for developing postoper-
Dr Friedman is Chairman, Department of Orthopaedic Surgery, Roper Hospital; Clinical Professor of Orthopaedic Surgery, Medical University of South Carolina, Charleston; and Medical Director of Charleston Orthopaedic Associates.
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Stakeholder Perspective, page 122
Am Health Drug Benefits. 2012;5(2):115-122 www.AHDBonline.com Disclosures are at end of text
ative venous thromboembolism (VTE).2-4 VTE comprises both deep-vein thrombosis (DVT) and pulmonary embolism (PE). In the absence of thromboprophylaxis, proximal DVT occurs in approximately 5% to 36% of patients who have THA and TKA.5 PE occurs in 50% of patients with proximal DVT,4 and proves fatal in approximately 15% of these patients.6 VTE is also associated with significant long-term complications, such as postthrombotic syndrome, chronic thromboembolic pulmonary hypertension, and an increased risk of recurrent events.7 Postthrombotic syndrome develops in 23% to 60% of patients, often in the 2 years after a DVT, and approximately 10% of cases are considered to be severe.8 Approximately 4% of patients with PE are diagnosed with chronic thromboembolic pulmonary hypertension within 2 years9; approximately
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KEY POINTS ➤
➤
➤
➤
➤
➤
THA and TKA are common orthopedic procedures that improve a patient’s quality of life but are associated with a significant risk for postoperative VTE and long-term complications. The incidence of VTE can be effectively reduced with thromboprophylactics, including vitamin K antagonists, LMWHs, or fondaparinux. However, these agents are associated with management challenges that limit their use and increase the clinical and economic burden on patients, caregivers, and the US healthcare overall. Currently, 3 new oral anticoagulants are in different stages of development—rivaroxaban, apixaban, and dabigatran—with the first agent recently receiving FDA approval in the United States. The new oral anticoagulants offer several benefits over current thromboprophylactics, including fixed dosing thanks to their predictable pharmacokinetics, no requirement for coagulation monitoring, few drug–drug and drug–food interactions, and once-daily or twice-daily oral administration. When considering the best thromboprophylactic agent, the associated costs related to anticoagulation need to be taken into account, including costs for drug acquisition, mode of administration, and routine coagulation monitoring.
10% of patients who experience VTE after THA or TKA are readmitted to the hospital within 3 months after discharge.10 The incidence of VTE can be effectively reduced with the use of thromboprophylactics, including vitamin K antagonists, low-molecular-weight heparins (LMWHs), or fondaparinux (Arixtra). Thromboprophylaxis reduces the cumulative incidence of symptomatic VTE to 1.7% within 3 months of THA and to 2.3% within 3 months of TKA.11 However, these agents pose a number of management challenges that limit their use and increase the clinical and economic burden on patients, caregivers, and healthcare resources. Effective prophylaxis may also be complicated by poor adherence to guideline recommendations, possibly resulting from physicians’ concern about the risk for bleeding or the difficulties of maintaining prophylaxis in an outpatient setting. Newly developed oral anticoagulants have the potential to address many of the limitations associated with vitamin K antagonists, LMWHs, and fondaparinux. They may also simplify treatment strategies for these patients, encourage compliance with therapy, and reduce the economic burden of VTE.
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The Economic Burden of VTE The costs of managing acute and chronic VTE are considerable, particularly those associated with hospitalization, long-term therapy, and monitoring.12,13 In the United States, management of VTE costs almost $500 million annually.13 A study using data from a large healthcare claims database showed that for patients with in-hospital VTE, mean billed charges were $18,834 higher than for matched controls (ie, individuals of the same age who underwent the same procedure but had no claim for DVT or PE); the increment was $7351 in TKA patients and $27,034 in THA patients.10 Another analysis of the economic burden of VTE in hospitalized patients estimated the cost of managing an initial episode of DVT to be between $7712 and $10,804, and between $9566 and $16,644 for an initial PE event.14 Long-term complications of VTE, such as recurrent VTE, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension, add to the cost of treatment.15-17 The cost of hospital readmission for a recurrent DVT is estimated to be 21% greater than the cost for the initial DVT event, mainly because of the longer hospital stay.16 The long-term costs of treating postthrombotic syndrome are estimated to add 75% to the cost of treating the initial DVT.17 The considerable morbidity associated with chronic thromboembolic pulmonary hypertension also adds to costs. The direct cost of managing patients with chronic thromboembolic pulmonary hypertension has been estimated to be $4782 per patient per month (PPPM) versus $511 PPPM for controls, with circulatoryrespiratory–related costs accounting for 55% of the excess costs.18 Although thromboprophylaxis reduces the incidence of VTE and its associated costs, the costs associated with anticoagulation need to be considered, including those for drug acquisition, administration, and routine coagulation monitoring. In addition, because the use of anticoagulants may increase the risk for bleeding, the cost of bleeding management should be taken into consideration. A recent analysis of insurance healthcare claims found that the monthly incremental costs per patient are similar for the management of VTE and bleeding events ($2729 and $2696, respectively) in patients with major orthopedic surgery.19 However, the overall 3month risk for bleeding was substantially lower than the risk for VTE.19 Barriers to Optimal Thromboprophylaxis Although thromboprophylaxis can effectively reduce the incidence of VTE in patients undergoing THA or TKA, barriers to optimal thromboprophylaxis exist.
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These barriers include: • Poor implementation of guidelines • Bleeding concerns • Limitations of existing agents.
Poor Implementation of Guidelines for the Prevention of VTE Clinical practice guidelines for the prevention of VTE have been published by the American College of Chest Physicians (ACCP) every 3 years for more than 20 years.3,20 The most up-to-date version of these guidelines recommends the routine use of traditional anticoagulants—LMWHs, fondaparinux, vitamin K antagonists (ie, warfarin)—aspirin, or one of the new oral anticoagulants—rivaroxaban (Xarelto), dabigatran (Pradaxa), or apixaban (Eliquis)—for pharmacologic thromboprophylaxis in individuals who have undergone THA or TKA surgery.3 The American Academy of Orthopaedic Surgeons (AAOS) recently published updated guidelines for the prevention of VTE in patients undergoing THA or TKA.21 The AAOS recommends the use of mechanical compression devices in appropriate patients, in addition to pharmacologic agents.21 Retrospective analyses of data collected by the Global Orthopaedic Registry (GLORY) between June 2001 and December 2004 have demonstrated limited adherence to guidelines for VTE prophylaxis in the United States, with room for much improvement.22,23 One barrier to the implementation of guidelines in the United States may be the considerably shorter period of time that patients undergoing THA or TKA spend in the hospital compared with other countries. In the United States, median lengths of hospital stay are only 3 and 4 days for THA or TKA, respectively, and it is likely that the duration of prophylaxis recommended by the ACCP (10-35 days) is difficult to achieve in an outpatient setting.3,22 A retrospective cohort study has also showed that physicians often use lower-than-recommended doses of LMWH, inadequate bridging protocols when switching from injectable agents to warfarin (which takes 3-5 days to reach effective levels), and insufficient or no therapy after hospital discharge.24 Concerns about Bleeding Although the major complication of all anticoagulant therapy is bleeding, when thromboprophylaxis is administered postsurgically to patients undergoing THA or TKA, the rates of major bleeding events are low. Major bleeding with LMWH prophylaxis after THA or TKA is estimated to be between 3% and 5%.25 Major bleeding with warfarin use is also low (approximately 4% at a target international normalized ratio of 2.0) and is heavily
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dependent on the patient’s predisposing risk factors, such as comorbid conditions (eg, cancer, hypertension, heart disease, cerebrovascular disease, renal insufficiency, and paraplegia).25 Patient characteristics (eg, age and a history of bleeding), concomitant medications, and incorrect timing and/or dosing of the anticoagulant also contribute to bleeding risk.25 For example, a patient aged >75 years who weighs >50 kg and has compromised renal function is at an increased risk for a major bleeding event. Complications may be avoided by taking a highly conservative approach to anticoagulation in these individuals; therefore, the risk for bleeding with appropriate use of thromboprophylactics may be overestimated.26,27
Limitations of Current Agents Existing anticoagulants carry a number of limitations that contribute to suboptimal thromboprophylaxis in patients undergoing THA or TKA. LMWHs and fondaparinux are inconvenient, particularly in the outpatient setting, because they are administered parenterally, and their use may accrue significant costs related to home administration by nurses, patient training, and monitoring. In addition, all heparins, including LMWHs, carry the risk for heparin-induced thrombocytopenia, and long-term therapy is associated with osteoporosis.28 Orally administered warfarin has complex pharmacokinetic and pharmacodynamic properties and a narrow therapeutic window, making routine coagulation monitoring and dose adjustments essential.28,29 Warfarin also has a slow onset and offset of action, which means that patients already receiving warfarin may need to adhere to complicated perioperative bridging protocols. In addition, warfarin has multiple food and drug interactions, and its metabolism is susceptible to numerous genetic polymorphisms.28,29 The New Oral Anticoagulants Three new oral anticoagulants have undergone phase 3 clinical studies in patients undergoing THA or TKA in the United States (Table).30-40 Two of these agents— rivaroxaban and apixaban—are factor Xa inhibitors, whereas dabigatran is a direct thrombin inhibitor. The beneficial characteristics of these 3 new anticoagulants include41: • Fixed dosing as a result of their predictable pharmacokinetics • No requirement for coagulation monitoring • Few drug–drug and drug–food interactions • Once- or twice-daily oral administration. Rivaroxaban Rivaroxaban selectively blocks the active site of factor
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Table Phase 3 Clinical Trials of Rivaroxaban, Apixaban, and Dabigatran Prophylaxis after Total Hip or Knee Arthroplasty
Drug
Surgery
Study
Subcutaneous enoxaparin dose
Oral drug dose
RECORD1 (2008)30
31-39
RECORD2 (2008)31
Rivaroxaban: 31-39 Enoxaparin: 10-14
THA 40 mg once daily
Rivaroxaban TKA
TKA Apixaban THA
RECORD4 (2009)33
30 mg twice daily
ADVANCE-1 (2009)34
30 mg twice daily
40 mg once daily
ADVANCE-3 (2010)36
150 mg or 220 mg once daily 40 mg once daily
RE-MODEL (2007)39 RE-MOBILIZE (2009)40
2.5 mg twice daily 32-38
RE-NOVATE II (2011)38
30 mg twice daily
Primary efficacy outcome
Efficacy of study drug vs enoxaparin
Composite of any DVT, nonfatal PE, and death
Superior
10-14
10-14
ADVANCE-2 (2010)35
THA
TKA
10 mg once daily
RECORD3 (2008)32
RE-NOVATE (2007)37
Dabigatran
Duration, days
Did not meet noninferiority Superior Superior
28-35
220 mg once daily 150 mg or 220 mg once daily
Composite of symptomatic or asymptomatic DVT, nonfatal PE, and death
Composite of total VTE events and death
Noninferior a
6-10 12-15
Did not meet noninferiority
a
Dabigatran was superior to enoxaparin for reducing the risk of major VTE (secondary end point) in the RE-NOVATE II study. DVT indicates deep-vein thrombosis; PE, pulmonary embolism; THA, total hip arthroplasty; TKA, total knee arthroplasty; VTE, venous thromboembolism.
Xa and does not require a cofactor (such as antithrombin) for activity. Because rivaroxaban has predictable pharmacokinetic and pharmacodynamic properties and a low potential for interactions with food or other drugs, it can be administered as a fixed dose, without the requirement for routine coagulation monitoring.42 A large phase 3 investigative program composed of 4 clinical trials that compared rivaroxaban with enoxaparin (Lovenox) in patients undergoing THA or TKA— Regulation of Coagulation in Orthopaedic Surgery to Prevent Deep Vein Thrombosis and Pulmonary Embolism (RECORD)—has been completed.42 The pri-
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mary efficacy end point of the 4 RECORD studies was total VTE—the composite of any DVT, nonfatal PE, and all-cause mortality (Table).30-33 The RECORD1 trial demonstrated that rivaroxaban 10 mg once daily was superior to enoxaparin 40 mg once daily for 30 to 35 days after THA,30 whereas the RECORD2 study demonstrated the superiority of longterm thromboprophylaxis with rivaroxaban 10 mg once daily (31-39 days) versus short-term thromboprophylaxis with enoxaparin 40 mg once daily (10-14 days) in patients undergoing THA.31 The RECORD3 and RECORD4 studies demonstrated the superior efficacy
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Oral Anticoagulants after Total Hip or Knee Arthroplasty
of rivaroxaban 10 mg once daily versus enoxaparin 40 mg once daily and 30 mg twice daily (a regimen approved in North America after TKA), respectively, for 10 to 14 days after TKA.32,33 In a pooled analysis of the RECORD studies, rivaroxaban significantly reduced the composite of symptomatic VTE and all-cause mortality versus enoxaparin and was associated with a similar safety profile.43 In July 2011, rivaroxaban became the first new oral agent to be approved by the US Food and Drug Administration (FDA) in the United States for prophylaxis of DVT (which may lead to PE) in patients undergoing THA or TKA, based on results from the RECORD1, 2, and 3 trials. The Centers for Medicare & Medicaid Services has issued a memo that rivaroxaban administration after THA and TKA is Surgical Care Improvement Project–compliant as of July 2, 2011.
Apixaban Another oral, direct factor Xa inhibitor, apixaban, has also been studied in phase 3 trials in patients undergoing THA or TKA (Table).34-36 Apixaban is currently approved for the prevention of VTE after THA or TKA in the European Union. In the Apixaban Versus Enoxaparin for Thromboprophylaxis After Knee Replacement (ADVANCE)-1 trial, apixaban 2.5 mg twice daily was compared with enoxaparin 30 mg twice daily in patients post-TKA. However, apixaban did not meet the prespecified statistical criteria for noninferiority for the composite primary efficacy end point of asymptomatic and symptomatic DVT, nonfatal PE, and death from any cause during treatment.34 In the ADVANCE-2 and ADVANCE-3 trials, apixaban 2.5 mg twice daily was compared with enoxaparin 40 mg once daily and demonstrated superior efficacy in patients who had undergone TKA (ADVANCE-2) and THA (ADVANCE-3).35,36 Apixaban compared with enoxaparin was not associated with an increase in bleeding events in any of the 3 ADVANCE studies.34-36 Dabigatran Dabigatran etexilate is an oral direct thrombin inhibitor that has a low potential for drug–drug interactions and a predictable anticoagulant effect.44 Dabigatran is approved for VTE prophylaxis after THA/TKA surgery in Canada and the European Union, but not currently in the United States. Dabigatran 150 mg or 220 mg once daily demonstrated noninferiority to enoxaparin 40 mg once daily for 28 to 35 days after THA in the RE-NOVATE and RENOVATE II studies, and for 6 to 10 days after TKA in the RE-MODEL study (Table).37-39 In the RE-MOBILIZE study (TKA), dabigatran failed to meet the noninferior-
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ity criteria when compared with enoxaparin 30 mg twice daily.40 Dabigatran had a similar safety profile versus enoxaparin in all 4 studies.37-40
Limitations of the New Oral Anticoagulants Despite their important advantages―oral administration, a rapid onset and offset of action, predictable pharmacokinetics that allow fixed dosing, no requirement for coagulation monitoring, and significantly fewer food–drug and drug–drug interactions than warfarin―the new oral anticoagulants also have some limitations. Although to date rivaroxaban is the only anticoagulant approved in the United States for use in orthopedic patients, efficacy and safety data from phase 3 clinical trials facilitate assessment of the limitations of dabigatran and apixaban as well. Renal function is very important for dabigatran; 80% is renally excreted, with the remainder excreted via the bile.44,45 There has been recent concern regarding excess bleeding in patients receiving dabigatran. These reports are currently being investigated by the FDA. The rivaroxaban dose must be adjusted in patients with renal insufficiency, and its use should be avoided in patients with severe renal impairment (creatinine clearance
