Current Controversies in Management of Anticoagulation for Atrial Fibrillation

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1 Current Controversies in Management of Anticoagulation for Atrial Fibrillation Cheri Silverstein Fadlon, MD MSCR Assistant Professor of Internal Medicine, COMP Cardiologist, Western Diabetes Institute Oversight physician, WesternU Anticoagulation Program

2 Disclosures I have no financial relationships to disclose

3 Questions: Part A 1. A 76 year old woman who has been on dabigatran (Pradaxa) for nonvalvular atrial fibrillation presents to your office for follow up. She reports that she was watching TV late at night and saw someone saying that patients might have an unnecessarily high risk of bleeding if Pradaxa levels are not checked. How do you counsel her? 2. A 75 year old man with a history of Type II diabetes mellitus, hypertension and heart failure with preserved ejection fraction is scheduled in your office for a new patient visit. He was recently discharged from a local hospital where he was started on dabigatran 150mg BID for thromboembolic prevention due to atrial fibrillation. You review his laboratory results and note that his creatinine is 2.64 with an estimated GFR of 22. What is your next step in management?

4 Questions: Part B 3. A 65 year old man with a history of hypertension and atrial fibrillation is scheduled to see you in follow up after he was discharged from the hospital after being admitted for a Non STEMI 1 week ago. He received a drug eluting stent and was discharged home on warfarin, aspirin and clopidogrel. What is your next step in management? 4. A75 year old woman with a history of hypertension, diabetes, heart failure with preserved ejection fraction and atrial fibrillation on warfarin for many years is found to have a breast mass. The breast surgeon asks for your guidance regarding management of her anticoagulation in the peri operative period. How do you counsel the patient and surgeon?

5 Outline Non Vitamin K Oral Anticoagulants Relevance Review of coagulation pathway Review of key trials Dabigatran controversies Complexities of the Factor Xa inhibitors Good clinical practice for NOACs CAD + anticoagulation for atrial fibrillation Bridging for vitamin K antagonists

6 WHY ARE NON VITAMIN K ANTAGONIST ORAL ANTI COAGULANTS RELEVANT TO YOU?

7 NOAC use growing rapidly Per FDA: Oct 2010 Dec 2013: 6.2 million dabigatran Rx; 934,000 from US outpatient retail pharmacies Study of database of a large insurer to identify patients with non valvular atrial fibrillation prescribed oral anti coagulation initiated anticoagulation. By end of study period non vitamin K antagonist oral anti coagulants: 62% of new prescriptions 98% of prescription cost Desai, N.R., Krumme, A.A., Schneeweiss, S. et al. Patterns of initiation of oral anticoagulants in patients with atrial fibrillation quality and cost implications. Am J Med May 2

8 BRIEF REVIEW OF ANTICOAGULANT BIOCHEMISTRY

9 Targets of Vitamin K antagonists Gulseth M, ed. Managing anticoagulation patients in the hospital. Bethesda, MD: American Society of Health System Pharmacists; 2007.

10

11 THE KEY TRIALS

12 RE LY trial ,113 with Afib with 1 other risk factor Excluded creatinine clearance < 30ml/min 1 o outcome: time to stroke or systemic embolism 1 o safety outcome: time to major hemorrhage 110mg vs Dabigatran BID 150mg warfarin

13 Non inferiority Upper bound of 1 sided 97.5% CI for hazard ratio < 1.46

14 RE LY trial 110mg = Dabigatran 150mg : GI bleeding dyspepsia in dabigatran (has acid coating) MI in dabigatran Warfarin time in range: 64% 150mg =

15 ROCKET AF ,264 with Afib with CHADS 2+ Creatinine clearance given lower 15mg dose 1 o outcome: time to stroke or systemic embolism 1 o safety: time to major + nonmajor clinically relevant bleeding vs Rivaroxaban 20mg daily warfarin

16 ROCKET AF 2011 Rivoraxaban Patel MR et al. N Engl J Med 2011;365: = Warfarin time in range: 55%

17 ARISTOTLE ,201 with Afib/flutter + 1 CHADS 2 risk factor Half dose if 2+ bleeding risks: age 80+, 60kg, creatinine o outcome: time to stroke or systemic embolism 1 o safety: major bleeding by ISTH criteria vs Apixaban 5mg BID warfarin

18 ARISTOTLE 2011 Apixaban Warfarin time in range: mean 62.2% Granger CB et al. N Engl J Med 2011;365:

19 AVERROES 2011 Apixaban vs ASA (1 4 81mg tablets) 5599 with Afib/flutter + 1 risk factor & not suitable for warfarin Connolly SJ et al. N Engl J Med 2011;364:

20 ENGAGE AF TIMI ,026 with Afib/flutter + CHADS 2 2+ Half of EITHER dose if CrCl 30 50, weight 60kg or on potent P glycoprotein inhibitor 1 o outcome: time to stroke or systemic embolism 1 o safety: major bleeding by ISTH criteria 30mg vs Edoxaban DAILY 60mg warfarin

21 ENGAGE AF TIMI Low dose Edoxaban = (Non inferior) High dose Edoxaban ( GI bleeding) Giugliano RP et al. N Engl J Med 2013;369:

22 SO WHAT ARE THE CONTROVERSIES?

23 Dabigatran FDA approval 110mg not approved in US FDA: 110mg a disadvantage, prescribers will overuse Strokes worse than bleeding 57% of patients who had a major bleed resumed or did not stop study drug. Additional bleeds no different In CrCl 30 50: ½ stroke rate, = bleeding in 150mg Approved 75mg BID for patients with CrCl based on company pharmacokinetic and pharmacodynamic data

24 Early dabigatran bleeding signal

25 Dabigatran bleeding risk factors 7000 patients started dabigatran in NZ in first 2mo available Reviewed 44 bleeds over 2 mo Prescriber error: INR not < 2 before starting Use in severe renal impairment Renal: 58% in moderate or severe renal impairment Age: 2/3 in age > 80 Weight: 50% < 60kg Harper P et al. N Engl J Med 2012;366:

26 2012 abstract: age 80 had bleeds on dabigatran 150mg vs warfarin Circulation. 2012; 126: A15537 RE LY re analysis using weighting of events: J Am Coll Cardiol. 2013;62(10):

27 Dabigatran MI signal FDA Medicare study 134,000 patients HR crosses 1 Meta analysis of randomized trials OR of MI Included DVT/valve studies Jonathan Douxfils et al. J Am Heart Assoc 2014;3:e000515

28

29 Pradaxa dose monitoring British Medical Journal (BMJ) concerns Five fold variation in blood plasma concentration Renal function + age, gender important Bleeds: 26.1% by 10 days of starting, 67.8% by 30 days Heart valve study with adjustment: 8% < 50ng/mL on 300mg BID 2011 draft paper said optimal balance of safety and efficacy: ng/mL Internal mathematical modeling: dose adjustment by level could reduce major bleeds by 30 40% compared to warfarin Delay in publication to preserve marketing advantage

30 J Am Coll Cardiol Feb 4;63(4): Counterpoints: Mathematical model did not predict clinical outcomes when applied to RE LY population Fixed dose dabigatran still non inferior to warfarin and safer than no treatment Monitoring may improve safety, but needs testing in clinical trial

31 Summary of dabigatran controversies There is not good data to support the use in CrCl < 30mg/mL There may be an increased risk of MI but likely does not outweigh benefit in most Dose variability does not invalidate fixed dose non inferiority to warfarin Dose adjustment based on levels may improve outcomes over fixed dosing but would need testing in trial

32 WHAT ABOUT THE OTHER 3?

33 NOAC absorption/metabolism

34 P glycoprotein (aka MDR1) ATP binding cassette transporter Extrudes toxins out of cells Inhibitors of P gp: Verapamil, Amiodarone, Dronaderone, Quinidine Azoles, Calcineurin inhib, HIV protease inhib Inducers of P gp: Phenytoin, Carbamazepine, St. John s Wort NOACs do not inhibit CYP3A4 or P gp

35 Edoxaban and renal function FDA did NOT approve edoxaban in those with NORMAL renal function (CrCl > 95ng/dL) Trend toward worse efficacy vs warfarin Overall stroke hazard ratio 1.41 (95% confidence interval ) Ischemic stroke HR 1.58 ( 95% ).

36 GOOD CLINICAL PRACTICE

37 Practical Issues for NOACs First follow up 1mo Then every 3mo Monitor adherence (pill counts) Symptoms of embolism Bleeding Other side effects Other medications Europace 2013; 15: , DOI: /europace/eut083

38 Blood tests Hemoglobin, renal and liver AT LEAST yearly Renal function every 6mo if CrCl or dabigatran > 75yrs/otherwise fragile Renal function every 3mo if CrCl If any medical condition that may affect liver or renal function develops Europace 2013; 15: , DOI: /europace/eut083

39 Measuring anticoagulant effect Peaks 1 4 hours; troughs hours Dabigatran: aptt increased: QUALITATIVE Ecarin Clotting Time: Not easily available Hemoclot (diluted thrombin time): Not FDA approved PT, anti Xa chromogenic assay: edoxaban, rivaroxaban

40 Summary of NOAC use Pay attention to renal function There are drug and dietary interactions Don t adjust dose for nuisance bleeding There are no approved reversal agents yet (idarucizumab under review). Still, bleeding not worse. NOACs not an advantage for those who have a history of missing doses regularly NNT is high (Lancet meta analysis ARR 0.7%, NNT 142) to prevent stroke/embolism Current ACC/AHA guidelines Class I for VKA or NOAC

41 CORONARY DISEASE + AFIB

42 PCI in Atrial fibrillation Single vs Dual anti platelet + VKA: bleeding risk 4 6% vs 10 14% ACC/AHA guidelines Consider bare metal stent Afib guidelines: Anticoagulation + clopidogrel alone(iib) based on WOEST (Lancet. 2013;381: ) which showed decreased bleeding without increased thrombosis NSTEMI guidelines: not enough data in NSTEMI. Minimize triple therapy duration. Could consider PPI, INR Data sparse on newer antiplatelet (prasugrel, ticagrelor) & NOACs; await PIONEER AF PCI

43 ISAR TRIPLE: Drug eluting stent in Afib 6wk vs 6mo triple therapy After 6wk analysis (BARC bleeding) Composite Ischemic TIMI Bleeding J Am Coll Cardiol. 2015;65(16):

44 Stable CAD + Atrial Fibrillation CORONER registry: 4184 patients ¾ of patients on VKA also on ASA HR for bleed 7.30 (95% CI ) ASA + VKA, 1.69 (95% CI ) VKA alone. No difference in MI/stroke/cardiovascular death ACCP guidelines say no aspirin if on anticoagulation (2C) Limited data: Individualize

45 Summary of CAD + Afib Limited data to guide us Know what kind of stent (bare metal vs DES) Don t forget to plan a stop date for triple therapy after ACS/stent Consider anticoagulation alone in stable CAD Mechanical valves : VKA + ASA

46 BRIDGING FOR PROCEDURES

47 Limited data: balance thrombosis vs bleeding BRIDGE trial still pending Continue VKA for minor procedures No bridging: stop VKA 2 4 days pre start 12 24hrs post Bridging: start when INR < 2 (48 72hrs pre) stop LMWH hours pre; stop heparin 4 6hrs pre Bridging of VKAs

48 Review NOACs have benefits but consider renal function, drug interactions NOACs : missing pills more dangerous and harder to detect We may overuse antiplatelet therapy in CAD patients on anticoagulation Limited data on bridging for warfarin in atrial fibrillation

49 Key References Heidbuchel H, Verhamme P, Alings M, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non valvular atrial fibrillation. Europace. 2013;15: January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Jr, et al AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64:e1 76. doi: /j.jacc Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence Based Clinical Practice Guidelines. Chest. 2012;141(2_suppl):7S 47S. doi: /chest.1412s3.

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