VTE and anti Xa's

[Bostonredsox]

Last weeks NEJM

Oral Apixiban for the treatment of acute venous thromboembolism.

5,000+ pts. Noninferior efficacy. Less major bleeding. Less minor bleeding.

How does this fit into your guys thinking in our previous rivarox vs warfarin debates.

I also read a a study showing a trend towards an all cause mortality reduction in addition to stroke prophylaxis superiority with apixiban compared with warfarin in AF therapy, looking for it now.

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[Hernandez]

Noninferior efficacy. Less major bleeding. Less minor bleeding.

How does this fit into your guys thinking in our previous rivarox vs warfarin debates

You answered you own question. You'd really need to dig through the stats to know if the bleeding issue is powered to detect that.

 

[Laryngophed]

When they bleed, how are you going to reverse it? Throw FFP or PCC at it? At least with warfarin you know what the answer is when it comes to "patient has hemoglobin of 6 g/dL and black, tarry stools for the last week. Oh, and they take coumadin for a fib."

 

[Bostonredsox]

When they bleed, how are you going to reverse it? Throw FFP or PCC at it? At least with warfarin you know what the answer is when it comes to "patient has hemoglobin of 6 g/dL and black, tarry stools for the last week. Oh, and they take coumadin for a fib."

We've gone over this extensively, the pts with ICHs who come in on Coumadin, they die. Give all the FP you want, they still die.

And as for the no fatal GI bleeds, we give FFP and some vitamin k, but apart from that, we treat symptomaticly, blood fluids and hemodynamic support. The anti XAs should be the same supportive care. And he tarry stool with a Hb of 6....well the latest guidelines recommend transfusing non lethal bleeding to a goal Hb of only 7... So the pt you described...I'd give a unit of blood and some volume and monitor there hemodynamics for 24-48 hours till the xa wore off...essentially the same thing I do with Coumadin.

It might just be me, but I don't think, "it's ok if you have a much higher chance of bleeding on warfarin, like 3x as much intracranially, because we can TRY and reverse it if you do, whereas we can't reverse the bleeding on the anti ax that you have a significantly lower chance of bleeding on anyway".... Is a good way to practice medicine.

The rivaroxaban and dabigitran data is noninferior with higher rates of non fatal go bleeding....apixiban is lower rates of all safety outcomes and noninferiority for the primary goal.

To me that's the description of a better drug.

If gut/onc is peering in....what are your thoughts on this for PE/dvt in the setting of malignancy?
My understanding of the updated chest guidelines is warfarin is still the preferred agent in malignancy, though I not sure as to why.

 

[jdh71]

Who funded the study?

 

[Bostonredsox]

Who funded the study?

Well atleast that's an intelligent question and of course the answer is Bristol Myers and Pfizer.

Data still looks legit to me though. Not saying everyone is getting apixiban, but in general I am giving out a lot less warfarin over the last few months

 

[ORL10]

Agree 150% with boston, blood in the brain on coumadin is bad. We all try our best to reverse and hope this improves outcomes, but no one has ever done, nor will anyone likely do, that study. You probably can give kcentra or FEIBA for most hemorrhages with decent reversal, I use it for life-threatening hemorrhages on ANY blood thinner currently. We use an INR based strategy for FEIBA, and a units/kg strategy for pradaxa, and xarelto (havent seen any apixiban bleeds yet). This isn't based on a RCT, just local policy.

I love the idea of a patient comes into the ED, has a DVT/PE and I discharge them home with a pill. If the PESI score or whatever other score you want to use is low enough for you to feel comfortable with discharge a pill is a hell of a lot easier than lovenox bridged to warfarin and a PMD follow-up.

My question is what is the cost going to be and what do my uninsured patients do? (currently I have a pharmacy that is set up with our hospital that pays for the lovenox initially since it is cheaper than a 2 day stay in the hospital.)

 

[Bostonredsox]

Not exactly a VTE pertaining notion but last weeks nejm had the high dose dabigitran vs warfarin valvular fib study.......

Stopped early due to bleeding deaths with dabigitran. Looks like warfarin is going to hang around for a long time in terms of the valve pts.