The new oral anticoagulants, do they change the benefit vs. risk for thromboprophylaxis in association to ambulatory surgery?

Abstract

Several randomized controlled trials have shown that pharmacological thromboprophylaxis with low-dose unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux reduces venous thromboembolism (VTE) after general surgery. No high-quality evidence supports the use of pharmacological thromboprohylaxis with traditional antithrombotic drugs in patients undergoing ambulatory surgery without additional VTE risk factors, stratified at low risk of VTE by the American College of Chest Physicians guidelines. Two new drug classes, the direct thrombin and factor Xa (FXa) inhibitors, have been developed with a potentially better risk-benefit profile. Oral administration, predictable anticoagulant responses, low potential for drug-drug interactions render direct thrombin and factor Xa inhibitors good candidates to replace UFH, LMWH and fondaparinux for VTE prophylaxis. Most of all, the positive results of the first published clinical trials in orthopedic thromboprophylaxis allowed dabigatran etexilate and rivaroxaban to be licensed in Canada and in European Union for the prevention of VTE in patients undergoing hip-replacement and knee-replacement surgery. No randomized trials with the new anticoagulants are ongoing in ambulatory surgery. However, currently available drugs--that is UFH, LMWH or fondaparinux--are administered subcutaneously and the new anticoagulants would offer the clear advantage of an oral administration, without request for blood testing to monitor potential adverse effects such as heparin-induced thrombocytopenia, thus potentially simplifying the treatment out of the hospital.