ialysis may reduce drug levels.58 The following AZD2281 Olaparib steps provide a therapeutic guideline for patients with severe bleeding events: delay the next administration of NOAC, if the patient is treated with oral FXa inhibitors, consider activated carbon depending on the intake time, if the patient is treated with dabigatran, consider hemodialysis, consider usual treatment for bleeding, including endoscopic, surgical, or interventional bleeding control, blood transfusion, and fresh frozen plasma, and if bleeding cannot be controlled or emergency surgery is indicated, consider administration of procoagulants such as PCC. If bleeding cannot be controlled, FEIBA or rVIIa may be used according to the guidelines. Of note, neither PCC nor rVIIa is approved for management of NOAC associated bleeding complications.
Conclusion Thromboprophylaxis in MOS is still an important issue, and the development of new oral anticoagulants has led to advances AG-490 in both efficacy and safety in this indication. Apixaban as one of the new oral direct FXa inhibitors has been shown to be highly effective and safe to prevent VTE complications in patients undergoing elective hip or knee replacement. Provided that personnel and patients are instructed that high treatment compliance is required, it can be expected that apixaban will achieve this benefit over parenteral prophylaxis also in unselected patients in daily care. Implementation of NOACs in thromboprophylaxis in daily care is simple, but specific pharmacological differences exist between apixaban, rivaroxaban, and dabigatran.
Consequently, the choice of substance should reflect local specifics such as pre existing experience with new oral anticoagulants, use of spinal catheters and timing of removal, proportion of older or renally impaired patients, typically used comedications, and preference of a late postoperative start or a once daily regimen. Therefore, the authors do not recommend the use of different NOACs for thromboprophylaxis on the same orthopedic ward. Furthermore, we strongly recommend the implementation of standard operating procedures for NOAC use in orthopedic surgery to enhance compliance and avoid errors in dosing and management problems, or catheter removal without interruption of NOAC, all of which may cause harm to the patient.
If oral FXa inhibitors such as apixaban are used in MOS prophylaxis, no dose adjustments for age, gender, or renal function are necessary, provided that renal function has a glomerular filtration rate above 15 mL/min. Furthermore, no routine monitoring is required. Finally, major bleeding complications will be rare with NOAC thromboprophylaxis, and management of these will be comparable with that of bleeding complications in patients receiving LMWH prophylaxis, because all NOACs have predictable pharmacokinetics with comparatively short half lives. Disclosures SW, KH, and JBW were investigators in numerous Phase III trials investigating apixaban, rivaroxaban, edoxaban, and dabigatran in VTE prophylaxis, VTE treatment, and stroke submit your manuscript | www.dovepress.com Dovepress Dovepress 145 VTE prophylaxis in major orthopedic surgery Therapeutics and Clinical Risk Management 2012:8 prevention in atrial fibrillation. SW received honoraria from Bayer Healthcare for lectures. JBW received honoraria from Bayer Healthcare, Bristol Myers Squibb, Pfizer, and Boehringer Ingelheim for lectures, serves as a member of advisory boards of Bayer Healthcare, Bristol Myers Squibb, and Pfi