which noac for which patient? - ici...
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Preventing Stroke and Managing Atrial Fibrillation Patients
Which NOAC for Which Patient?
Amos Katz, M.D.
Grant/Research Support:
Pfizer, - Boehringer Ingelheim, - Bayer, - Daiichi Sankyo, - Cardio 3, - Sanofi, TIMI group, - Trevena, - Hamilton Health Sciences Corporation, Population Health Research Institute, - Novartis
Speaker’s Bureau:
Pfizer, - Bayer. - Boehringer Ingelheim, - BIOTRONIK, -Medtronic, - Sanofi, - Novartis
Consultant:
BIOTRONIK, - Spirocor
Disclosures
New / Novel Oral Anticoagulants (NOACs)
Non-warfarin Oral Anti Coagulants (NOACs)
Non-vitamin K antagonist oral anticoagulants (NOACs)
Target-Specific Oral anti Coagulants (TSOCs)
Direct Oral Anti Coagulants (DOACs)
Oral Direct Inhibitors (ODIs)
Non-monitored Oral Anti Coagulants (NOACs)
NOACs? - No longer new or novel
Most strokes associated with AF are ischaemic
Based on data collected in the Danish National Indicator Project for 39 484 patients hospitalized for stroke (80% of all stroke admissions in Denmark) including 6294 patients with AF); OAC use not recorded
Andersen KK et al. Stroke 2009;40:2068–72 4
Types of stroke in patients with AF
Ischaemic
92% (n=5810)
Haemorrhagic
8% (n=484)
NOAC Phase III Trials Timelines
• AVERROS
• Double blind
• Vs. Aspirin
NOAC
Europe Approved June 26, 2015
FDA Approved January 8, 2015
Pharmacological Characteristics and Rx dose of NOAC
in Phase III Trials
RELY (Dabigatran )
ROCKET (Rivaroxaban)
ARISTOTLE (Apixaban)
ENGAGE-AF (Edoxaban)
Mechanism of action
Selective direct FIIa inhibitor
Selective direct FXa inhibitor
Selective direct FXa inhibitor
Selective direct FXa inhibitor
Oral bioavailability, %
6.5 80-100 50 62
Half-life, h 12-17 5-13 8-15 6-11
Renal elimination % 85 66 (36 unchanged &30 inactive)
27 50
Time to maximal inhibition, h
0,5-2 1-4 1-4 1-2
Potential for drug–drug interactions
P-gp inhibitor CYP3A4 substrate and P-gp inhibitor
CYP3A4 substrate and P-gp inhibitor
Study treatment Dabigatran 110mg BID
Dabigatran 150mg BID
Rivaroxaban 20mg
(15 in pts with eFGR
30-49 ml/min)
QD
Apixaban 5mg
2.5 mg in age > 80 Y,
weight < 60 kg, creat < 1.5mg/dl
BID
Edoxaban 30mg QD
Edoxaban 60mg QD
Connolly S et al NEJM 2009; Patel M et al NEJM 2011; Granger C et al NEJM 2011; ENGAGE- AF Study Investigators. AHJ 2010
CRNM-clinically relevant non-mjor
Baseline Characteristics
All NOACs; Stroke or Systemic Embolic Events
Secondary Efficacy Outcome
All NOACs; Major Bleeding
Safety outcomes of NOACs vs. warfarin: Data from RE-LY, ROCKET AF and ARISTOTLE
NA=not available; * Includes major and nonmajor clinically relevant bleeding events only
Based on an indirect comparison, where dabigatran , rivaroxaban and apixaban were all compared against the reference drug warfarin (target INR 2-3).
Connolly SJ et al. N Engl J Med 2009;361:1139–51; Connolly SJ et al. N Engl J Med 2010;363:1875–6 ; Patel MR et al. N Engl J Med 2011;365:883–91 ; Granger CB et al. N Engl J Med 2011;365:981–92
Apixaban 5mg BID
Rivaroxaban 20mg OD
Dabigatran 110mg BID
Dabigatran 150mg BID
Major bleeds
ICH
NA Life-threatening bleeds
Major GI bleeds
* Total bleeds
=
=
=
=
=
ROCKET AF Reveals Higher GI leeding Rates With
Rivaroxaban
• Retrospective analysis of the trial (14,236 patients in the safety-end-point population of trial)
• GI bleeding rates were 42% higher for rivaroxaban-treated patients (HR 1.42, 95% CI 1.22–1.66), than for warfarin
• 48% - upper-GI tract
• 23% - lower-GI tract
• 29% - rectum
Sherwood M,et al. J Am Coll Cardiol 2015; 66:2271-2281
NOACs: Absorption & Metabolism
H. Heidbuchel et al. Updated EHRA practical guide for use of the non-VKA oral anticoagulants. Europace 8/2015
Drug–drug interactions
H. Heidbuchel et al. Updated EHRA practical guide for use of the non-VKA oral anticoagulants. Europace 8/2015
Drug–drug interactions
H. Heidbuchel et al. Updated EHRA practical guide for use of the non-VKA oral anticoagulants. Europace 8/2015
Approved European labels for NOACs and
their dosing in CKD
H. Heidbuchel et al. Updated EHRA practical guide for use of the non-VKA oral anticoagulants. Europace 8/2015
תהיה בטוח שבחרת נכון
NOACs – Dose Reduction
• VKA is protective after an ACS, Warfarin plus aspirin reduces the risk
of recurrent ischaemic
• Triple therapy with DAPT and NOACs - doubles the risk of major
bleeding after an ACS.
• Studies evaluating combinations of NOAC or VKA + antiplatelets post
PCI & stenting
• PIONEER AF PCI – Rivaroxaban; ongoing
• RE-DUAL PCI – Dabigatran ; ongoing
• AUGUSTUS - Apixaban ; ongoing
• EVOLVE-AF-PCI – Edoxaban; to start
• Unknown whether SAPT/DAPT plus NOAC is safer than
SAPT/DAPT plus VKA or vice versa.
NOACS in Patient with Atrial Fibrillation & CAD
H. Heidbuchel et al. Updated EHRA practical guide for use of the non-VKA oral anticoagulants. Europace 8/2015
• Dabigatran and edoxaban have not been evaluated in a Phase III study of
patients with recent ACS.
• In a meta-analysis of dabigatran trials, there was a significantly higher rate of
MIs with dabigatran vs. VKA (odds ratio 1.33, 95% confidence interval1.03–
1.71, P ¼ 0.03)
• The absolute excess was very low (about 3 per 1000 patients)
• The net clinical benefit and mortality benefit of dabigatran over VKA was maintained in AF
patients with a previous MI,
• No excess of MI was observed in a Danish registry & in an FDA conducted US Medicare registry
• No trial with FXa inhibitors showed a statistically significant excess of MI.
• After ACS, DAPT on top of apixaban (5 mg BID) significantly increases major
and fatal bleeding risk, without reduction in ischaemic events (APPRAISE-2 )
• Phase II trial with dabigatran in combination with DAPT after ACS, showed a
dose-dependent increase in bleeding events
• Rivaroxaban (2.5 mg BID) on top of DAPT significantly improves ischaemic
outcome after ACS, but is associated with increased major and intracranial
bleeding (ATLAS ACS)
NOACS in Patient with Atrial Fibrillation & CAD
H. Heidbuchel et al. Updated EHRA practical guide for use of the non-VKA oral anticoagulants. Europace 8/2015
NOAC Antidotes – Clinical Trials
• Electrical cardioversion in patients treated with NOACs has a similar
(and very low) thrombo-embolic risk as under warfarin
• Subgroup analyses from:
• RE-LY (dabigatran)
• ROCKET-AF (rivaroxaban),
• ARISTOTLE (apixaban)
• The recently published X-VeRT trial confirmed the low peri-
cardioversion stroke risk in patients treated with rivaroxaban compared
with warfarin
• Ongoing Clinical Studies:
• ENAMATE – Rivaroxaban
• ENSURE – Adoxaban
NOACS & Cardioversion
H. Heidbuchel et al. Updated EHRA practical guide for use of the non-VKA oral anticoagulants. Europace 8/2015
Adherence
Discontinuation
Patients Preference vs. Safety
Pan X et al. ESC 2014, Barcelona, Spain. Oral poster presentation, ESC 2014. Accessible on congress365.escardio.org
% O
F PA
TIEN
TS W
ITH
DIS
CO
NTI
NU
ATI
ON
TIME FROM ANTICOAGULATION INITIATION (DAYS)
WARFARIN (n=14,339)
RIVAROXABAN (n=12,080)
DABIGATRAN (n=4,495)
APIXABAN (n=2,956)
Warfarin vs. Apixaban: Adjusted HR: 1.638 (95% Cl: 1.514–1.772) P<0.001 Rivaroxaban vs. Apixaban: Adjusted HR: 1.215 (95% Cl: 1.121–1.317) P<0.001 Dabigatran vs. Apixaban: Adjusted HR: 1.581 (95% Cl: 1.451–1.721) P<0.001
Analysis controlled for other variables including age, gender, onset of embolic or primary ischaemic stroke, dyspepsia or stomach discomfort, congestive heart failure, coronary artery disease, diabetes, hypertension, renal disease, myocardial infarction, history of TIA or stroke and history of bleeding
0
0
10
20
40
60
70
30 60 90 120 150 180 210 240 270 300 330 360 390
30
50
BMS/Pfizer confidential. For internal use only. Not for further distribution
Discontinuation Rates In USA NVAF Patients New To Anticoagulation (Jan 2013 – Dec 2013) (Marketscan Commercial and Medicare)
The proportion of patients who discontinued
during the follow-up period was:
• 23.32% for apixaban
• 46.96% for dabigatran
• 35.15% for rivaroxaban • 46.28% for warfarin
Conclusions:
• The twice-daily dosing regimen of NOACs appears to offer a more
balanced risk-benefit profile with respect to stroke prevention and
intracranial bleeding.
Real Life Data
FDA analysis on Dabigatran Jan 2014
Surveillance plan for rivaroxaban
Danish Registry
FDA study of Medicare patients finds risks lower for stroke and death but higher for gastrointestinal bleeding with Pradaxa
(dabigatran) compared to warfarin (13.5.2014)
Larsen TB, et al. J Am Coll Cardiol 2013; 61: 2264-73.
Real World Comparison Of Major Bleeding Risk Among Non-valvular
Atrial Fibrillation Patients Newly Initiated On Apixaban, Dabigatran,
Rivaroxaban Or Warfarin (poster ESC 2015 LIP)
Which is the est NOACS?
• No Head to head comparison
• CHADS2 score and more secondary prevention pts. In
ROCKET AF
• Ischemic Stroke reduction only with dabigatran 150 mg
BID
• GI bleeding in the trials: • Increased with:
• Dabigatran 150 mg
• Rivaroxaban
• Edoxaban 60 mg
• Not increased with:
• Apixaban
• Edoxaban 30 mg
• Decreased in total mortality:
• Rivaroxaban
• Edoxaban 30 mg
NOACs – Indirect Comparison
Double-blind study
VKA unsuitable
M F/U 1.1 years.
NEJM February 10, 2011
•DMC recommended early study termination at 1st analysis of efficacy – May 28, 2010
• 4 SD x 2 in favour of apixaban
•Long-term open-label apixaban follow-up*
•94% patients received apixaban 5 mg BID
•91% patients received aspirin ≤162 mg daily
•Median follow-up: 1.1 year
Adapted from Camm et al. Clinical Cardiology on line December 2013.
2015
A= Apixaban, D=dabigatran, E= edoxaban, R=rivaroxaban
Watchman LAA Closure Technology
The WATCHMAN LAA Closure Technology is designed to prevent embolization of thrombi that may form in the LAA.
The WATHCMAN Left Atrial Appendage Closure Technology is intended as an alternative to warfarin therapy for patients with non-valvular atrial fibrillation.
If all else fails - LAA Closure Device
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Preventing Stroke and Managing Atrial Fibrillation Patients
Which NOAC for Which Patient?
Amos Katz, M.D.
41
A proposed algorithm to aid in the selection of
NOACs in the patients with non-valvular AF
Abhishek Maan. J Thorac Dis 2015;7(2):115-131
תהיה בטוח שבחרת נכון
ARISTOTLE:
Stroke/SE and Major Bleeding According to Renal Function