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Pharmacoeconomic evaluation of dabigatran, rivaroxaban and apixaban versus enoxaparin for the prevention of venous thromboembolism after total hip or knee replacement in Spain.
[heparin-induced thrombocytopenia]
Patients
undergoing
total
hip
replacement
(
THR
)
or
total
knee
replacement
(
TKR
)
surgery
are
at
high
risk
of
developing
venous
thromboembolism
(
VTE
)
.
Thromboprophylaxis
with
low
-molecular-weight
heparin
,
such
as
enoxaparin
,
is
standard
of
care
in
these
patients
.
Recently
,
three
direct
oral
anticoagulants
(
DOACs
;
dabigatran
,
rivaroxaban
and
apixaban
)
,
have
been
approved
for
this
indication
,
but
their
cost
effectiveness
is
still
unclear
as
it
has
usually
been
extrapolated
from
surrogate
venographic
outcomes
in
clinical
trials
.
To
conduct
a
pharmacoeconomic
evaluation
of
the
DOACs
versus
subcutaneous
(
SC
)
enoxaparin
for
the
prevention
of
VTE
after
THR
or
TKR
surgery
.
A
decision-tree
model
was
developed
using
TreeAge
Pro
2011
to
compare
the
cost
utility
and
cost
effectiveness
of
the
DOACs
with
SC
enoxaparin
,
with
separate
models
for
THR
and
TKR
over
a
3
-
month
postoperative
time
horizon
from
the
perspective
of
the
Spanish
National
Health
System
.
The
probabilities
of
events
(
symptomatic
VTE
,
clinically
relevant
bleedings
,
heparin-induced
thrombocytopenia
and
deaths
)
were
derived
from
a
systematic
review
and
meta
-analysis
.
We
used
local
cost
estimates
(
€
2013
)
and
utility
values
were
obtained
from
the
literature
.
We
reported
costs
,
quality-adjusted
life-
years
(
QALYs
)
and
symptomatic
VTE
events
.
We
conducted
sensitivity
analyses
to
evaluate
parameter
uncertainty
.
The
average
costs
per
1
,
000
patients
treated
with
enoxaparin
were
higher
than
costs
incurred
by
dabigatran
,
rivaroxaban
and
apixaban
in
THR
(
€
435
,
208
vs
.
€
283
,
574
,
€
257
,
900
and
€
212
,
472
,
respectively
)
and
TKR
(
€
336
,
550
vs
.
€
219
,
856
,
€
251
,
734
and
€
201
,
946
,
respectively
)
,
with
cost
savings
ranging
from
€
151
,
634
to
€
222
,
766
in
THR
,
and
from
€
84
,
816
to
€
134
,
604
in
TKR
.
Cost
differences
were
largely
driven
by
differences
in
costs
associated
with
drug
administration
.
The
average
QALYs
per
1
,
000
patients
treated
were
very
similar
for
enoxaparin
,
dabigatran
,
rivaroxaban
and
apixaban
in
THR
(
199
.
34
,
198
.
83
,
199
.
08
and
199
.
68
,
respectively
)
and
TKR
(
198
.
95
,
199
.
41
,
198
.
75
and
199
.
97
,
respectively
)
.
Rivaroxaban
(
in
TKR
and
THR
)
and
apixaban
(
in
THR
)
avoided
additional
symptomatic
VTE
events
compared
with
enoxaparin
.
Sensitivity
analyses
generally
supported
the
robustness
of
the
analysis
to
changes
in
model
parameters
.
Our
model
suggests
,
based
on
its
underlying
assumptions
and
data
,
that
the
DOACs
are
cost-saving
alternatives
to
SC
enoxaparin
for
the
prevention
of
VTE
after
THR
or
TKR
,
in
the
Spanish
healthcare
setting
.
Diseases
Validation
Diseases presenting
"total knee replacement"
symptom
heparin-induced thrombocytopenia
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