NPC Archive Item: NICE publishes guidance on rivaroxaban▼ for prevention of VTE after hip and knee surgery

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5th May 2009

NICE technology appraisal guidance 170▼ recommends oral rivaroxaban (Xarelto®) as an option for the prevention of venous thromboembolism (VTE) in adults having elective total hip replacement surgery or elective total knee replacement surgery.

Healthcare professionals involved in the management of adults undergoing orthopaedic surgery should be aware of this and other related NICE guidance. Oral rivaroxaban▼ is one of the options to consider within the NHS for prophylaxis of VTE in patients having hip or knee replacement surgery. Other options to consider, in accordance with their licensed indications, are injectable agents such as low-molecular weigh heparin (LMWH) or fondaparinux and the other oral agent dabigatran etexilate. Please refer to the following NICE guidance for further information:

  • Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. NICE clinical guideline 46 (2007).
  • Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults. NICE technology appraisal guidance 157 (2008).
  • In addition, NICE is developing guidance on prevention of VTE in all patients admitted to hospital, which will incorporate CG 46.  NICE expects to issue this guidance in November 2009.

    NICE has developed tools to help organisations put this guidance into practice: a costing statement explaining the resource impact of this guidance and audit support for monitoring local practice.

    According to NICE clinical guideline 46, patients having orthopaedic surgery should be offered LMWH, e.g. enoxaparin, for prevention of VTE. Fondaparinux, within its licensed indications, is an alternative to LMWH.

    Dabigatran etexilate and rivaroxaban, unlike LMWH and fondaparinux, are orally active anticoagulants. Both are licensed for use in patients undergoing elective total hip or knee replacement surgery. Previously NICE has recommended (NICE TAG 157) dabigatran etexilate as an alternative option to LMWH (or fondaparinux) in these patients. Following a review of the clinical and economic evidence (see TAG 170 for details), the NICE Appraisal Committee concluded that rivaroxaban, enoxaparin (a commonly used LMWH) and dabigatran etexilate had very similar costs and benefits in the prevention of VTE in these patients. They agreed that rivaroxaban for the prevention of VTE was an appropriate use of NHS resources in these circumstances.

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