The potential role of new therapies in deep-vein thrombosis prophylaxis

The value of prophylaxis against venous thromboembolism (VTE) is increasingly accepted in most surgical specialties, although the potential reduction in fatal pulmonary embolism has recently been questioned. The burden of VTE in hospital patients nevertheless remains high, partly attributable to underuse of thromboprophylaxis and partly attributable to occurrence of VTE in high-risk patients because recommended antithrombotic therapies fail to provide full protection. Improved physician education has been shown to increase the application of antithrombotic measures, and research efforts are focused on developing novel antithrombotic agents with greater efficacy and safety in clinical use. Several novel indirect and direct thrombin inhibitors have been investigated. The heparinoid danaparoid has shown superiority over unfractionated heparin in several indications, but only the recombinant hirudin, desirudin, has exhibited greater efficacy than low-molecular-weight heparin (LMWH) in thromboprophylaxis for patients undergoing elective hip-replacement surgery, without increasing the risk of bleeding. Three large-scale clinical trials have shown desirudin to be the most effective thromboprophylactic agent currently available in elective hip-replacement surgery; this agent has now been licensed for use in orthopedic surgery. Research is ongoing into the feasibility of still more effective and convenient therapies, such as oral antithrombins.