Education - New oral anticoag

Shorter hospital stays lead to greater need for easy to use anticoagulants within community setting according to Britain’s leading Primary Care anticoagulation expert

There will be an increased role for anticoagulation management within Primary Care, according to one of Britain’s leading anticoagulation experts, given shorter hospital stays and a new oral anticoagulant available for the first time to the NHS for fifty years from today (Monday April 21^st 2008).

Professor David Fitzmaurice, Professor of Primary Care Research at the University of Birmingham believes that Primary Care will benefit because there will be less pressure on PCTs to provide district nursing support to patients post surgery with the advantage of a daily pill, which does not require constant monitoring like warfarin, or an injection, like heparin.

Dabigatran etexilate (Pradaxa), is the first of a new class of oral anticoagulants – a direct thrombin inhibitior – to be made available in the UK. The initial licence for Pradaxa is for the prevention of blood clots (VTEs – or venous thromboembolisms) in adult patients who have undergone hip or knee replacement surgery.

Professor Fitzmaurice says, “Given the trend for shorter hospital stays following joint replacement surgery and longer duration of thromboprophylaxis, it is becoming increasingly important to have anticoagulant treatments available which are well tolerated and easy to use in the community. Pradaxa, taken orally once daily, may be an attractive alternative to thromboprophylaxis regimens currently used to prevent VTE in patients undergoing elective hip and knee replacement surgery that often requires district nursing support.”

Dr Beverley Hunt, Medical Director of the thrombosis charity Lifeblood says, “The prevention of blood clots with blood thinners after surgery is not done well in the UK. One of the problems is that current blood thinners can only be given as an injection. We therefore very much welcome the arrival of a tablet for adults undergoing hip and knee surgery. The need for and potential impact of a generally well-tolerated oral anticoagulant that does not require monitoring, is profound.”

Many of the 131,000 UK patients² who every year undergo total hip or knee replacement are at high risk of venous thromboembolism (VTE); without thromboprophylaxis as many as 60 per cent will go on to develop DVT (deep vein thrombosis; including asymptomatic thrombi). One quarter to one third of these thrombi involve the proximal deep veins, resulting in a greater likelihood of symptoms and PE (pulmonary embolism).³

Guidelines, including those published by NICE last year, recommend that patients undergoing elective hip replacement surgery with one or more risk factors for VTE (i.e. over the age of 60 years) should continue to receive thromboprophylaxis for 4 weeks after their operation.⁴ Similarly, it is recommended that patients undergoing total knee replacement surgery receive up to 10 days thromboprophylaxis.³

However a paper published in The Lancet this January concluded that whilst a large proportion of hospital patients are at risk of VTE, there is a low rate of appropriate preventative measures used. Findings from the study revealed that in the UK less than 4 in 10 medical patients receive recommended prophylaxis⁵.

Moreover, a recently published Department of Health report highlighted that VTE caused in excess of 25,000 deaths per annum in UK hospitals, exceeding the combined total of deaths from breast cancer, AIDS and traffic accidents, representing 25 times the incidence of MRSA.⁶

One of the most commonly used anticoagulants in this patient group is low molecular weight heparin (LMWH), which must be administered - often by the patient - as an injection. As Pradaxa ^Ò is given as a fixed oral dose, it can be taken conveniently both in and out of the hospital setting.

Pradaxa ^Ò does not require anticoagulation monitoring^*, having a rapid onset and offset of action and a predictable anticoagulation effect.

Professor Simon Frostick, Professor of Orthopaedics at the University of Liverpool said,

“Given the trend for shorter hospital stays following joint replacement surgery and longer duration of thromboprophylaxis, it is becoming increasingly important to have anticoagulant treatments available which are well tolerated and easy to use in an out-patient setting. Pradaxa^® taken orally once daily may be an attractive alternative to other thromboprophylaxis regimens currently used to prevent VTE in patients undergoing elective hip and knee replacement surgery.”