title: New anticoagulants as thromboprophylaxis after total hip or knee replacement.
abstract: OBJECTIVE
  Due to a high risk of thromboembolism in patients undergoing major orthopedic surgery, it has become standard practice to give thromboprophylactic treatment. We assessed the relative efficacy and cost-effectiveness of two new oral anticoagulants, rivaroxaban and dabigatran, relative to subcutaneous enoxaparin for the prevention of thromboembolism after total hip replacement (THR) and total knee replacement surgery (TKR).
  
  
  METHODS
  We conducted a systematic review of the literature to assess efficacy and safety, and evaluated quality of documentation using GRADE. Cost-effectiveness was assessed by developing a decision model. The model combined two modules; a decision tree for the short-term prophylaxis and a Markov model for the long-term complications and survival gain.
  
  
  RESULTS
  For rivaroxaban compared with enoxaparin, we found statistically significant decreases in deep vein thrombosis, but also a trend toward increased risk of major bleeding. For mortality and pulmonary embolism there were no statistically significant differences between the treatments. We did not find statistically significant differences between dabigatran and enoxaparin for our efficacy and safety outcomes. Assuming a willingness to pay of EUR62,500 per QALY, rivaroxaban following THR had a probability of 38 percent, and enoxaparin following TKR had a probability of 34 percent of being cost-effective. Clinical efficacy had the greatest impact on decision uncertainty.
  
  
  CONCLUSIONS
  Dabigatran and rivaroxaban are comparable with enoxaparin following THR and TKR regarding the efficacy and safety outcomes. However, there is great uncertainty regarding which strategy is the most cost-effective. More research on clinical efficacy of rivaroxaban and dabigatran is likely to change our results.
authors.affiliation: Norwegian Knowledge Centre for the Health Services, Oslo, Norway.
authors.forename: Vida
authors.initials: V
authors.lastname: Hamidi
authors.forename: Tove
authors.initials: T
authors.lastname: Ringerike
authors.forename: Gunhild
authors.initials: G
authors.lastname: Hagen
authors.forename: Åsmund
authors.initials: Å
authors.lastname: Reikvam
authors.forename: Marianne
authors.initials: M
authors.lastname: Klemp
mesh_terms: D000925:Anticoagulants / Q000191:economics / Q000627:therapeutic use*; D000991:Antithrombins / Q000191:economics / Q000627:therapeutic use*; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D001562:Benzimidazoles / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D000069604:Dabigatran; D006801:Humans; D009025:Morpholines / Q000191:economics / Q000627:therapeutic use*; D017063:Outcome Assessment, Health Care; D061214:Patient Safety; D011292:Premedication / Q000191:economics; D000069552:Rivaroxaban; D013876:Thiophenes / Q000191:economics / Q000627:therapeutic use*; D013923:Thromboembolism / Q000517:prevention & control*; D015091:beta-Alanine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D000991:Antithrombins; D001562:Benzimidazoles; D009025:Morpholines; D013876:Thiophenes; D015091:beta-Alanine; D000069552:Rivaroxaban; D000069604:Dabigatran