Epilogue

The new anticoagulants, with their oral route of administration and no requirement for coagulation monitoring, will simplify the management of thromboprophylaxis. Their convenience and lack of interaction with food and with other drugs should improve patient adherence to therapy, resulting in a reduced incidence of deep vein thrombosis and pulmonary embolism in patients after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The improved efficacy of rivaroxaban compared with the current standard of care for in-hospital prophylaxis, enoxaparin, should also mean fewer embolic events, and should result in cost savings and improved quality of life after THA/TKA.¹ The new national and local strategies to increase appropriate use of thromboprophylaxis whenever appropriate^2,3 should also produce substantial reductions in in-hospital vascular embolic events. These reductions in events should translate into reductions in long-term complications, with further cost savings⁴ and a reduction in the burden of disease for patients.^5-7

This supplement has highlighted the changes that will probably occur once the new anticoagulants are used to prevent venous thrombosis after THA and TKA. If these agents do prove to be cost-effective, they will be responsible for dramatically reducing the burgeoning economic burden on the healthcare system-particularly due to venous thromboembolism following total joint replacement surgery. Compared with 2005 values, the annual numbers of procedures in the United States are predicted to rise from 285,000 to 572,000 THAs and from 523,000 to 3,480,000 TKAs by 2030.⁸ Therefore, even modest reductions in cost compared with those associated with the use of current anticoagulants would translate into significant savings with an important impact on the allocation of healthcare resources. In recent technology appraisals of rivaroxaban⁹ and dabigatran,¹⁰ both were found to be associated with an increase in quality-adjusted life-years, so the new anticoagulants should also reduce the burden of illness for patients. While these observations remain speculative at this time, recent clinical trial results with these promising new agents provide great cause for optimism.

1. McCullagh L, Tilson L, Walsh C, Barry M. A cost-effectiveness model comparing rivaroxaban and dabigatran etexilate with enoxaparin sodium as thromboprophylaxis after total hip and total knee replacement in the Irish healthcare setting. Pharmacoeconomics. 2009;27:829-846.

2. Geerts W. Prevention of venous thromboembolism: a key patient safety priority. J Thromb Haemost. 2009;7(suppl 1):1-8.

3. Michota FA. Prevention of venous thromboembolism after surgery. Cleve Clin J Med. 2009;76(suppl 4):S45-S52.

4. Caprini JA, Botteman MF, Stephens JM, et al. Economic burden of long-term complications of deep vein thrombosis after total hip replacement surgery in the United States. Value Health. 2003;6:59-74.

5. Kahn SR. The post-thrombotic syndrome: the forgotten morbidity of deep venous thrombosis. J Thromb Thrombolysis. 2006;21:41-48.

6. Pengo V, Lensing AW, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350:2257-2264.

7. Becattini C, Agnelli G, Pesavento R, et al. Incidence of chronic thromboembolic pulmonary hypertension after a first episode of pulmonary embolism. Chest. 2006;130:172-175.

8. Iorio R, Robb WJ, Healy WL, et al. Orthopaedic surgeon workforce and volume assessment for total hip and knee replacement in the United States: preparing for an epidemic. J Bone Joint Surg Am. 2008;90:1598-1605.

9. Stevenson M, Scope A, Holmes M, Rees A, Kaltenthaler E. Rivaroxaban for the prevention of venous thromboembolism: a single technology appraisal. Health Technol Assess. 2009;13 (suppl 3):43-48.

10. Holmes M, Carroll C, Papaioannou D. Dabigatran etexilate for the prevention of venous thromboembolism in patients undergoing elective hip and knee surgery: a single technology appraisal. Health Technol Assess. 2009;13(suppl 2):55-62.

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