Noacs use in patients other than atrial fibrillation

NOACs- Non Atrial
Fibrillation indications.
Respective trials
Dipak Patade

NOACs
• Options for anticoagulation expanding steadily over the past few
decades
• a greater number of agents for prevention and management of
thromboembolic disease.
• In addition to heparins and vitamin K antagonists, anticoagulants that
directly target the enzymatic activity of thrombin and factor Xa have
been developed.
• Appropriate use of these agents requires knowledge of their
individual characteristics, risks, and benefits.

Other acronyms
orally acting direct thrombin inhibitors and direct factor Xa inhibitors
also known as:
• direct oral anticoagulants (DOACs),
• target-specific oral anticoagulants (TSOACs),
• oral direct inhibitors (ODIs), and
• NOACs, which stands for "novel oral anticoagulants”

Clinical indications
1. Venous thromboembolism (VTE) prophylaxis (non-orthopedic)
2. VTE prophylaxis (orthopedic)
3. VTE treatment (individuals without cancer, initial anticoagulation)
4. VTE treatment (individuals without cancer, long-term
anticoagulation)
5. VTE treatment (individuals with cancer)
6. Atrial fibrillation (AF)
7. Acute coronary syndromes (ACS)
8. Heparin-induced thrombocytopenia (HIT)

Risk group Drug name Trial name
VTE prophylaxis Dabigatran RE-NOVATE I and RE-NOVATE II.
RE-MODEL, RE-MOBILIZE
Riveroxaban RECORD-1 TO 4
Apixaban ADVANCE -1 TO 3
VTE treatment Dabigatran RE-COVER I and RE-COVER II
Riveroxaban EINSTEIN-DVT ,EINSTEIN-PE
Apixaban AMPLIFY
VTE extension Dabigatran RE-MEDY, RE-SONATE
Riveroxaban EINSTEIN-EXT
Apixaban AMPLIFY-EXT
VTE recurrence Aspirin INSPIRE ,WARFASA
Riveroxaban EINSTEIN-CHOICE
CANCER VTE NOACS METANALYSIS
Riveroxaban SELECT-D

Risk group Drug name Trial name
CAD/PAD Riveroxaban COMPASS
HEART FAILURE Riveroxaban COMMANDER-HF
VTE PROPHYLAXIS IN MEDICAL PTS Riveroxaban MARINER
ACS Riveroxaban ATLAS ACS 2-TIMI 51 trial
GEMINI-1
Apixaban APPRAISE 2
Valvular HD Dabigatran RE-ALIGN
And yet many more to published soon ……………………………………

Dabigatran for Prophylaxis of DVT, Pulmonary Embolism and
After Hip Replacement Surgery
• prophylaxis of deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients
who have undergone hip replacement surgery.
• two randomized, double-blind, phase III trials :RE-NOVATE I and RE-NOVATE II.
• Endpoints:
• Primary efficacy endpoint: composite of total VTE and all-cause mortality during
treatment
Secondary efficacy endpoints: all-cause mortality, symptomatic DVT, distal DVT,
composite of fatal/non-fatal DVT and PE during follow-up
Primary safety endpoint: major bleeding
Secondary safety endpoints: composite of major and clinically relevant non-major
bleeding events, other bleeding events during treatment, liver enzyme elevation and
acute coronary events
• Trial participants:
• 3494 patients aged ≥18 years, scheduled for elective total hip replacement IN RE-
NOVATE I
• 2055 patients aged ≥18 years, scheduled for elective total hip arthroplasty IN RE NOVATE
II

RE-NOVATE CONCLUSIONS
• Oral dabigatran showed statistical non-inferiority to subcutaneous
enoxaparin for VTE and all-cause death.
• There was no significant difference between dabigatran and
enoxaparin for major VTE and VTE-related death.
• Safety: The rates of minor and major bleeding were comparable in all
3 study groups.

VTE treatment and secondary prophylaxis
• Randomized, double-blind phase III non-inferiority studies
• In the treatment of acute VTE and further secondary prevention
• RE-COVER I and RE-COVER II

RE-COVER I
• Active treatment: dabigatran 150 mg p.o. twice daily for 6 months
plus warfarin placebo after an initial treatment with a parenteral
anticoagulant (low molecular weight or unfractionated heparin) plus
warfarin placebo (sham INR) for at least 5 days (n=1274)
Control treatment: dose-adjusted warfarin (INR 2.0–3.0) for 6 months,
starting after randomization, plus dabigatran placebo, starting after at
least 5 days parenteral anticoagulation (n=1265)

Efficacy: Dabigatran was non-inferior to warfarin in the the prevention of recurrent or fatal VTE in
patients with acute VTE
Safety: In the dabigatran group, the rate of major or clinically relevant nonmajor bleeding events was
significantly lower as in the warfarin group. The difference in major bleeding was not significant

direct thrombin inhibitor dabigatran has similar effects on VTE recurrence and a lower risk of bleeding
compared with well-controlled warfarin for the treatment of acute VTE.
Pooled analysis of this study RE-COVER II and the RE-COVER I trial gave hazard ratios for recurrent
VTE of 1.09, for major bleeding of 0.73, and for any bleeding of 0.70

Efficacy: Oral rivaroxaban was significantly superior to subcutaneous enoxaparin for
thromboprophylaxis after total knee arthroplasty.
Safety: Although there were more major, major plus clinically relevant nonmajor, and any bleeding
events with rivaroxaban, the differences compared with enoxaparin were not statistically significant

The EINSTEIN DVT Study Design Included an
Initial Intensified Regimen of 'Xarelto'
 A single-drug approach with 'Xarelto' was used in EINSTEIN DVT
 An intensified dose of 'Xarelto' (15 mg bid) was given for the first 21 days to provide protection when patients are at
highest risk of recurrence
 After 21 days 'Xarelto' 20 mg od was given to provide continued protection against VTE recurrence
 Primary efficacy outcome: symptomatic recurrent VTE (composite of recurrent DVT, non-fatal PE or fatal PE)
 Principal safety outcome: composite of major or clinically relevant non-major bleeding
The EINSTEIN Investigators, 2010
15 mg bidObjectively
confirmed DVT
without
symptomatic PE
N=3449
'Xarelto'
Day 1 Day 21
Enoxaparin (1.0 mg/kg) bid for at least 5 days,
plus VKA target INR 2.5 (INR range 2.0–3.0)
Predefined treatment period of 3, 6 or 12 months
20 mg od
'Xarelto'
R
30-day
observation
period

Effective DVT Treatment Matters
Time to event (days)
Cumulativeeventrate(%)
0 30 60 90 120 150 180 210 240 270 300 330 360
0
1.0
2.0
3.0
'Xarelto' (N=1731)
Enoxaparin/VKA (N=1718)
4.0
HR=0.68 (95% CI 0.44–1.04)
p<0.001 for non-inferiority
p=0.08 for superiority
Intention-to-treat population
'Xarelto' and standard of care had similar efficacy in
the reduction of symptomatic recurrent VTE

Safety Matters: Similar Rates of Clinically
Relevant Bleeding
'Xarelto' (N=1718)
0 30 60 90 120 150 180 210 240 270 300 330 360
0
2
4
6
8
10
12
14
HR=0.97 (95% CI 0.76–1.22)
p=0.77
Safety population
'Xarelto' and standard of care had similar rates of
major and clinically relevant non-major bleeding

Relevant Bleeding
32
'Xarelto' Enoxaparin/VKA
n (%) n (%)
First major/clinically relevant
non-major bleeding
139 (8.1) 138 (8.1)
Major bleeding 14 (0.8) 20 (1.2)
Contributing to death 1 (<0.1) 5 (0.3)
In a critical site 3 (0.2) 3 (0.2)

'Xarelto'
(N=1731), %
Enoxaparin/VKA
(N=1718), %
HR (95% CI) p-value
Net clinical
benefit*
2.9 4.2
0.67
(0.47–0.95)
0.03
Favourable Benefit–Risk Balance Matters
*Defined as the composite of the primary efficacy outcome and major bleeding
4.2
2.9
0
1
2
3
4
5
Enoxaparin/VKA 'Xarelto'
Incidence(%)
RRR
33%
(p=0.03)

'Xarelto'
(N=1731)
Enoxaparin/VKA
(N=1718)
Male patients (%) 57.4 56.3
Age, mean (years) 55.8 56.4
Weight (%)
≤50 kg 2.1 2.9
>50–100 kg 83.4 82.8
>100 kg 14.2 14.3
Creatinine clearance (%)
<30 ml/min 0.3 0.5
30–<50 ml/min 6.6 7.0
50–<80 ml/min 22.7 23.2
≥80 ml/min 68.9 68.1
Patient Characteristics: Similar in Both
Study Arms in EINSTEIN DVT

'Xarelto'
(N=1731)
Enoxaparin/VKA
(N=1718)
Intended treatment duration (%)
3 months 12.0 11.8
6 months 62.6 63.0
12 months 25.4 25.1
Pretreatment with
LMWH/heparin/fondaparinux ≤48 h (%)
73.0 71.0
Active cancer (%) 6.8 5.2
Unprovoked VTE (%) 60.9 63.0
Patient and Treatment Characteristics:
Similar in Both Study Arms in EINSTEIN DVT

The EINSTEIN PE Study Design Included an
Initial Intensified Regimen of 'Xarelto'
 A single-drug approach with 'Xarelto' was used in the pivotal EINSTEIN PE study - the largest ever conducted in
the acute treatment of PE, involving haemodynamically stable patients
 An intensified dose of 'Xarelto' (15 mg bid) was given for the first 21 days to provide protection when patients are at
highest risk of recurrence
 After 21 days, 'Xarelto' 20 mg od was given to provide continued protection against VTE recurrence
 Primary efficacy outcome: symptomatic recurrent VTE (composite of recurrent DVT, non-fatal PE or fatal PE)
 Principal safety outcome: composite of major or clinically relevant non-major bleeding
The EINSTEIN–PE Investigators, 2012
15 mg bidObjectively
confirmed PE
with or without
symptomatic DVT
N=4832
'Xarelto'
Day 1 Day 21
Enoxaparin (1.0 mg/kg) bid for at least 5 days,
plus VKA target INR 2.5 (INR range 2.0–3.0)
Predefined treatment period of 3, 6 or 12 months
20 mg od
'Xarelto'
R
30-day
observation
period

Effective PE Treatment Matters
3.0
2.5
2.0
1.5
1.0
0.0
0.5
0 30 60 90 120 150 180 210 240 270 300 330 360
'Xarelto' (N=2419)
HR=1.12 (95% CI 0.75–1.68)
p=0.003 (non-inferiority)
p=0.57 (superiority)
'Xarelto' also showed consistent
efficacy across subgroups
'Xarelto' and standard of care had similar efficacy in
the reduction of symptomatic recurrent VTE

Effective PE Treatment Matters
38

Relevant Bleeding
'Xarelto'
n/N (%)
Enoxaparin/VKA
n/N (%)
HR (95% CI)
p-value
249/2412
(10.3)
274/2405
(11.4)
0.90 (0.76–1.07)
p=0.23
0 30 60 90 120 150 180 210 240 270 300 330 360
15
14
10
13
12
11
9
8
7
6
5
4
3
2
1
0
'Xarelto' (N=2412)
Cumulativeeventrate(%) 'Xarelto' also showed consistent
safety across subgroups
Safety population
Major or clinically relevant non-major bleeding

3.0
2.5
2.0
1.5
1.0
0
0.5
0 30 60 90 120 150 180 210 240 270 300 330 360
'Xarelto' (N=2412)
Significant Reduction: Halving the Risk of
Major Bleeding
Safety population
'Xarelto' reduced major bleeding by 51%
compared with standard of care, with large reductions in
critical site bleeding

Significant Reduction: Halving the Risk of Major Bleeding
41
'Xarelto' Enoxaparin/VKA HR (95% CI)
p-valuen (%) n (%)
Major bleeding 26 (1.1) 52 (2.2)
0.49 (0.31–0.79)
p=0.003
Fatal 2 (<0.1) 3 (0.1)
Non-fatal critical site 7 (0.3) 26 (1.1)
Intracranial 1 (<0.1) 10 (0.4)
Retroperitoneal 1 (<0.1) 7 (0.3)

'Xarelto' can be Used in a Wide Range of
Haemodynamically Stable PE Patients
 Efficacy and safety outcomes were consistent across key patient subgroups, including elderly
patients and those with renal impairment
 'Xarelto' was effective regardless of the severity of PE, whether it was anatomically limited
(≤25% of vasculature of a single lobe) or extensive (multiple lobes and >25% of entire
pulmonary vasculature)
 'Xarelto' was associated with a similar rate of adverse events compared with standard of care
 This included serious adverse events and treatment-emergent adverse events
 There was no evidence of liver toxicity in patients who received 'Xarelto'

Efficacy: Apixaban was similarly effective in preventing VTE after total knee arthroplasty.
Safety: Apixaban was superior to enoxaparin for major and clinically relevant bleeding episodes

Apixaban after the initial Management of PuLmonary embolIsm
and deep vein thrombosis with First-line therapY (2013)

Efficacy: For the treatment of acute VTE, a fixed-dose regimen of apixaban alone was non-inferior to conventional
treatment consisting of enoxaparin followed by warfarin
Safety: Treatment with apixaban was associated with significantly less major and clinically relevant non-major
bleeding

Efficacy: Dabigatran was as effective as well-controlled warfarin in the extended treatment of VTE and
secondary prevention of symptomatic VTE.
Safety outcome: Treatment with the direct thrombin inhibitor was associated with a reduced risk for
bleeding but an increased incidence of acute coronary events.

Efficacy: Extended treatment with rivaroxaban was superior to placebo in preventing symptomatic recurrent VTE. A
prespecified indicator of net clinical benefit (symptomatic recurrent VTE plus major bleeding) favored rivaroxaban
Safety: The incidence of major bleeding was similar in both groups. However, the rate of clinically relevant non-major
bleeding was higher in the patients assigned to rivaroxaban

Efficacy: Extended anticoagulation with apixaban at either a treatment dose (5 mg) or a thromboprophylactic dose
(2.5 mg) resulted in a large and significant reduction in the risk of recurrent fatal or non-fatal VTE.
Safety: Both of the regimen of apixaban were safe. The rates of major bleeding in the apixaban groups were low and
similar to those in the placebo group.

ASPIRE and WARFASA studies(INSPIRE
project) 2014
• The ASPIRE and WARFASA studies were independent, investigator-
initiated, randomized, double-blind, placebo-controlled, clinical trials
designed to examine the efficacy and safety of low-dose
aspirin100mg in the extended treatment of VTE.
• Eligible patients were those with a first episode of unprovoked VTE,
defined as proximal deep-vein thrombosis (DVT) or pulmonary
embolism (PE), who had completed initial treatment with heparin and
warfarin or an equivalent anticoagulant regimen.
• Venous thromboembolism was considered as unprovoked when it
occurred in the absence of any known specific permanent or
temporary clinical risk factor.

ASPIRE and WARFASA studies(INSPIRE project) 2014
• prospective, combined analysis of the WARFASA and ASPIRE trials
provides clear evidence that –
• aspirin reduces the risk of recurrent VTE events by ≈40% and is a very
safe and effective therapy.
• Although it does not reduce the rate of VTE by as much as vitamin K
antagonists or newer oral anticoagulants (direct thrombin inhibitors
or factor Xa inhibitors), among patients for whom such therapies are
not considered appropriate or are discontinued, aspirin should be
strongly considered.
Aspirin for the Prevention of Recurrent Venous Thromboembolism.The INSPIRE
Collaboration ,circulation September 23, 2014
Vol 130, Issue 13

SELECT-D study
• Pilot study
• 406 patients
• Riveroxaban 15 mg BID x 21 days f/b 20 mg OD vs LMWH dalteparin
200U/kg x 1 month f/b 150 U/kg for 12 months
• Reduced VTE recurrence ( 4 % vs 11 %)
• Rate of major bleeding almost same( 6% vs 5.5 % )
• Similar results have been shown by Edoxaban in similar pilot studies
• Studies favors Edoxaban over Riveroxaban for Cancer related VTE
• Study with Apixaban is ongoing.

ATLAS ACS 2-TIMI 51 trial
Anti-Xa Therapy to Lower cardiovascular events in addition to Aspirin with or without
thienopyridine therapy in Subjects with Acute Coronary Syndrome 2 – Thrombolysis
in Myocardial Infarction 51 Trial (2011)
• Acute coronary syndromes arise from coronary atherosclerosis with
superimposed thrombosis. Since factor Xa plays a central role in
thrombosis, the inhibition of factor Xa with low-dose rivaroxaban
might improve cardiovascular outcomes in patients with a recent
acute coronary syndrome.
• compared rivaroxaban 2.5 mg or 5 mg twice daily (unlike the 20 mg
once-daily dose for atrial fibrillation) with placebo in 15,526 patients
following ACS.
• At a mean follow-up of 13 months, the primary efficacy endpoint of
CV death, MI or stroke ,Rates of definite, probable or possible stent
thrombosis were analysed

• The use of rivaroxaban 2.5 mg twice daily, might be considered in
combination with aspirin and clopidogrel if ticagrelor and
prasugrel are not available for NSTEMI patients who have high
ischaemic and low bleeding risks.
• In patients with a recent acute coronary syndrome, rivaroxaban
reduced the risk of the composite end point of death from
cardiovascular causes, myocardial infarction, or stroke.
• Rivaroxaban increased the risk of major bleeding and intracranial
hemorrhage but not the risk of fatal bleeding.

Low-dose 2.5-mg
rivaroxaban
demonstrated
reduced risk of death
from cardiovascular
(CV) causes,
myocardial infarction
(MI), or stroke
Increased risk of
major bleeding and
intracranial
hemorrhage, but not
fatal bleeding

APPRAISE 2
• assessed the effects of the oral factor Xa inhibitor apixaban 5 mg
twice daily compared with placebo, in addition to standard-of-care
antiplatelet therapy following ACS.
• It was terminated early (median 8 months) due to a markedly
increased risk of severe bleeds, including intracranial haemorrhage,
without any apparent benefit in terms of ischaemic events.

• Low dose NOAC Riveroxaban 2.5
mg with SAPT after dropping
aspirin
• Possible less repeat ACS vents with
less bleeding .

COMPASS trial
• In stable CAD/PAD patient
• Adding low dose Riveroxaban 2.5 BID with SAPT (Apsirin) increases
bleeding but reduces secondary event rates.

COMMANDER HF trial
• Heart failure is associated with activation of thrombin-related
pathways, which predicts a poor prognosis.
• Hypothesis: treatment with rivaroxaban, a factor Xa inhibitor, could
reduce thrombin generation and improve outcomes for patients with
worsening chronic heart failure and underlying coronary artery
disease.

NOAC for thromboprophylaxis
of general medical patients

Modified Caprini risk assessment model for
VTE in general surgical patients
• Cardiac surgery (moderate to high Caprini score) –rates of VTE up to 1
percent in this population (prophylaxis unknown) but older studies suggest
higher rates (up to 25 percent) in the absence of prophylaxis.
• Noncardiac thoracic surgery (moderate to high Caprini score) –
symptomatic VTE ranges from 0.18 to 7.4 percent (highest in
pneumonectomy, esophagectomy, extended resection)
• Neurosurgery (moderate to high Caprini score) – Meta-analyses report a
pooled incidence of VTE in untreated patients between 16 and 29 percent,
highest in those undergoing craniotomy
• Major trauma (moderate to high Caprini score) – While studies report an
incidence of DVT as high as 58 percent among those not receiving
prophylaxis these rates may reflect the most seriously ill patients with
multiple other injuries (eg, traumatic brain and spinal injury)

Noacs use in patients other than atrial fibrillation

Noacs use in patients other than atrial fibrillation

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