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New Anticoagulants for Thromboprophylaxis After Total Knee Arthroplasty

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New Anticoagulants for Thromboprophylaxis After Total Knee Arthroplasty A Review Paper New Anticoagulants for Thromboprophylaxis After Total Knee Arthroplasty Timothy S. Brown, MD, and Michael H. Huo, MD common of these complications. It has been estimated that, in Abstract the absence of effective chemoprophylaxis, the total incidence Total knee arthroplasty (TKA) is one of the most of deep vein thrombosis (DVT) and pulmonary embolism (PE) common orthopedic procedures in the United after major orthopedic surgery is as high as 41% to 85% and States. The number of TKAs is expected to 1.5% to 10%, respectively.3 rise significantly over the next 2 decades. One VTE is a major cause of postoperative morbidity and carries of the most common complications after TKA a significant risk for mortality.3 The cost of managing VTE is is venous thromboembolism (VTE), which is estimated to be as much as $1.5 billion annually in the US. potentially fatal. The incidence of VTE is effec- The cost of managing an initial DVT event is estimated to be tively reduced by prophylactic anticoagulants, $7712 to $10,804, and the cost of managing an initial PE event and clinical guidelines have been developed is estimated to be $9566 to $16,644.4 Appropriate use of effec- to improve VTE management. However, cur- tive thromboprophylaxis reduces the cumulative incidence of rent anticoagulants have limitations in terms of symptomatic VTE to 2.3% within 3 months after TKA.5 efficacy, safety, half-life, ease of administration, Anticoagulants increase the risk for bleeding. With that in and patient adherence. Moreover, these anti- mind, clinicians need to consider the cost of managing any coagulants require routine monitoring and dose bleeding event when assessing the overall cost savings associ- adjustment, and potential bleeding complica-AJOated with anticoagulant prophylaxis.6 Analyses of insurance tions represent an important concern. A new claims from the Ingenix National Managed Care (Impact) Da- generation of anticoagulants, including recently tabase revealed that, in patients who have had either TKA or approved rivaroxaban, is being developed to total hip arthroplasty (THA), the increased monthly health care address the shortcomings of current agents. cost associated with a VTE event was comparable with that of The efficacy and safety of these newer agents a bleeding event ($2729 vs $2696). are comparable with those of existing ones. The cost of a VTE event, however, was substantially lower DORivaroxaban is the only newNOT oral agent that is than that ofCOPY a major bleeding event ($2729 vs $4304).6 The approved for use in TKA and that has demon- overall 3-month risks for any bleeding or major bleeding event strated an efficacy superior to that of enoxapa- were lower (4.0% and 1.9%, respectively) than the risk for VTE rin in phase 3 trials. To optimize the manage- (6.7%). From a managed-care population perspective, the larg- ment of VTE prophylaxis after TKAs, orthopedic er incremental cost associated with major bleeding compared surgeons must have a thorough understanding with VTE was offset by the reduction in symptomatic events of these new oral agents. that would require additional treatment and hospitalization.6 This study and others emphasize the importance of balancing bleeding risk and use of effective thromboprophylaxis in the overall consideration of health care economics.6,7 otal knee arthroplasty (TKA) is one of the most com- Morbidity and mortality are a function of the high inci- mon orthopedic procedures in the United States (US). dence of VTE after TKA as well as the long-term sequelae of TMore than half a million surgeries are performed each VTE, including recurrence, postthrombotic syndrome, and year, and this figure is expected to rise to about 3.5 million chronic thromboembolic pulmonary hypertension. It is there- surgeries per year by 2030.1 fore necessary to optimize thromboprophylaxis in patients Patients who undergo TKA are at risk for a range of post- undergoing TKA. surgical complications, including wound-healing problems, In this review, we summarize some of the most clinically wound and deep-tissue infection, and venous thromboem- relevant data on the newer, recently approved anticoagulants bolism (VTE).2 VTE is potentially fatal and among the most and on the agents being developed for thromboprophylaxis Authors’ Disclosure Statement: Dr. Huo is a consultant for Biomet, DePuy-Synthes, IMDS; editorial member of Current Orthopedic Practice, Journal of Bone & Joint Surgery, J of Arthroplasty; speaker for Cadence and Janssen. Dr. Brown has no actual or potential conflicts of interest to disclose. 424 The American Journal of Orthopedics® September 2013 www.amjorthopedics.com A Review Paper Parenteral Indirect Agents Oral Direct Agents VII VIIa TF X IX TB-402 VIIa VKA: inhibit synthesis of factors II, VII, IX, X IXa Fondaparinux Rivaroxaban LM WH Antithrombin Apixaban UFH Edoxaban II Xa Betrixaban Darexaban (YM 150) Key: Va TAK-442 transformation catalysis activation inhibition Ximelagatran X inactive factor IIa Dabigatran (Thrombin) X active factor AJO AZD 0837 Fibrinogen Fibrin Figure. Targets for anticoagulants in use and in development as thromboprophylaxis after total knee arthroplasty.14,20,39 LMWH, low molecular weight heparin; UFH, unfractionated heparin; VKA, vitamin K antagonist. afterDO TKA. In addition, we discuss NOT current practice guidelines, in studies COPYof prophylactic treatment and for considering PE pharmacology, clinical trial data, and application of these new and fatal PE as the only valid outcomes. In contrast, the ACCP anticoagulants in real-life orthopedic practices. guidelines recognize a link between asymptomatic DVT and PE. The implications of this decision are described in a com- Clinical Practice Guidelines prehensive review by Eikelboom and colleagues.9 Both ACCP for Thromboprophylaxis and AAOS guidelines meet the standards of the Surgical Care Clinical practice guidelines for VTE prevention have been pub- Improvement Project (SCIP) of the Centers for Medicare and lished by the American College of Chest Physicians (ACCP) for Medicaid Services (CMS). Most hospitals have adopted one or more than 20 years, with the most recent update in 2012.3,8 the other to fulfill their compliance requirement with CMS. These evidence-based recommendations have helped to define For thromboprophylaxis after TKA, the ACCP guidelines the optimal use of thromboprophylaxis in patients undergo- recommend routine low-molecular-weight heparin (LMWH; ing TKA and are widely used throughout North America and enoxaparin or dalteparin), the pentasaccharide fondaparinux the rest of the world.9 In 2007, the American Academy of Or- (an indirect non-oral factor Xa inhibitor), or the vitamin K thopaedic Surgeons (AAOS) published its first set of clinical antagonist (VKA) warfarin.3 They did not recommend aspirin practice guidelines for VTE prevention in patients undergoing as a sole agent for thromboprophylaxis; however, aspirin and TKAs and THAs.10 AAOS released an updated version in 2011.11 sequential compression devices are included in the recom- There are some important differences between these guide- mendations.3,10 lines. The ACCP guidelines are for preventing both DVT and PE, The latest AAOS guidelines suggest pharmacologic agents whereas the AAOS guidelines specifically address preventing and/or mechanical compressive devices (grade of recom- death from PE after total joint arthroplasty (TJA). As a result, mendation: moderate) for thromboprophylaxis. The AAOS there were initially some significant areas of disagreement. suggests, however, that evidence is still unclear as to which The AAOS guidelines have been criticized for not considering prophylactic strategies are optimal, and it does not recom- the incidence of asymptomatic DVT as a meaningful endpoint mend for or against specific prophylactics in patients who have www.amjorthopedics.com September 2013 The American Journal of Orthopedics® 425 New Anticoagulants for Thromboprophylaxis After TKA T. S. Brown and M. H. Huo undergone TKA (grade of recommendation: inconclusive).11 fondaparinux is administered subcutaneously (SC) and lacks Controversy also exists regarding the appropriate duration the convenience of oral administration.14 The VKA warfarin, of thromboprophylaxis. The AAOS guidelines recommend which has been the principal oral anticoagulant for more than using a LMWH or fondaparinux for 7 to 12 days after surgery 60 years, has complex PK and PD properties, and its dose re- or warfarin for 2 to 6 weeks after surgery.10 However, they sponse is highly susceptible to genetic factors, drug–drug inter- also cite the fact that evidence is not sufficient for specific time actions, and food–drug interactions.14,15 In addition, warfarin recommendations (grade of recommendation: consensus) and has a narrow therapeutic window, making routine coagulation therefore suggest that patients and physicians discuss the dura- monitoring and dose adjustment essential15; it also has a slow tion of prophylaxis.11 onset (and offset) of action. Data from the Global Orthopaedic Registry (GLORY) sug- The efficacy of aspirin in the prevention of VTE after TKA gested that adherence to the guideline standards of throm- has been much debated. There are only a few randomized boprophylaxis was poor in real-world clinical practice. Poor controlled trials comparing aspirin to other antithrombotic adherence was particularly prevalent in the US. Thus, there agents. These studies have conflicting data of varying quality; remain unmet goals for optimizing thromboprophylaxis
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