Brockbank J, Wolowacz S. Economic evaluations of new oral anticoagulants for the prevention of venous thromboembolism after total hip or knee replacement: a systematic review. Pharmacoeconomics. 2017 May;35(5):517-35. doi: 10.1007/s40273-017-0486-4

BACKGROUND: Total hip replacement (THR) and total knee replacement (TKR) surgeries are being performed with increasing regularity and are associated with a high risk of developing a venous thromboembolism (VTE). New oral anticoagulants (NOACs) may be more effective at preventing VTEs but are associated with more bleeding events versus traditional anticoagulants.

OBJECTIVE: The objective of this systematic review was to identify published economic analyses of NOACs for primary VTE prophylaxis following THR and TKR surgeries and to summarise the modelling techniques used and the cost-effectiveness results.

METHODS: Electronic searches of MEDLINE, EconLit, and The Cochrane Library were performed from January 2008 to February 2015. Reference lists of included articles and reviews were examined for relevant studies.

RESULTS: Sixteen relevant economic analyses were identified. All used decision-tree structures to model acute events after surgery; 13 included a chronic-phase Markov module to capture long-term complications of VTE and recurrent VTE events. All studies included prophylaxis-related major bleeding events. All studies captured both symptomatic and asymptomatic VTE-related events; 9 studies distinguished between distal and proximal deep-vein thrombosis events. Rivaroxaban dominated enoxaparin in 8 of 11 studies and dalteparin in 1 study, dabigatran dominated enoxaparin in 5 of 7 studies, and apixaban dominated enoxaparin in 2 of 2 studies. Rivaroxaban dominated dabigatran in 4 of 4 studies, apixaban dominated dabigatran in 2 of 2 studies, and rivaroxaban dominated apixaban in 1 study.

CONCLUSIONS: The economic analyses showed reasonable consistency in the model structures used and the events captured. The results strongly suggested that NOACs are cost-effective alternatives to low molecular-weight heparin. Dabigatran appeared to be the least cost-effective NOAC. More research is needed to assess the cost-effectiveness of apixaban and edoxaban.

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