Why I choose apixaban
Secondary stroke prevention is achieved using targeted therapeutics. This is no secret. American Heart Association Guidelines recommend the use of aspirin in the acute setting of a cerebral infarction, but in cases of non-valvular atrial fibrillation, neurologists will often trade in aspirin for a stronger anticoagulant. Unfortunately, the algorithm for choosing an anti-coagulant is not so simple, so we’ve tried to summarize it in our latest episode of BrainWaves:
I wish I had a controlling interest in Bristol-Myers Squibb, but alas, I do not. I’m stuck with the available evidence in the medical literature which supports the use of NOACs in secondary stroke prevention for select patients with Afib. They are also great choices for deep vein thrombosis and pulmonary embolism. That being said, not every comer with Afib and stroke is eligible for a NOAC. All NOACs are contraindicated in patients on hemodialysis due to the higher risk of hemorrhage, and most NOACs require dose-adjustment for renal impairment or older age. I would have some reservations giving dabigatran to a triple-bypass patient, or rivaroxaban to a patient with peptic ulcer disease. And although mortality from NOAC-associated intracranial hemorrhage is high (45-67%), major bleeding complications are relatively rare (<5%), and reversal agents like idarucizumab are emerging within the pharmacologic market.
Summary. I’ve put together the bare minimum of tables here, comparing each of the NOACs against the previous standard-of-care (warfarin), which our episode discusses in greater detail. But for those of you who just want the high points…
This table is intended to illustrate statistically significant superiority or inferiority of each NOAC against warfarin in patients with stroke attributed to non-valvular atrial fibrillation. As you can tell from what’s been clearly bolded, apixaban is superior to warfarin for all major outcomes, and you won’t find that it is inferior to warfarin for any major adverse events.
That’s why I choose apixaban.
Connolly SJ, et al. Dabigatran versus warfarin in patients with atrial fibrillation. New Engl J Med 2009; 361:1139-1151.
Granger CB, et al. Apixaban versus warfarin in patients with atrial fibrillation. New Engl J Med 2011; 365:981-992.
Patel MR, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. New Engl J Med 2011; 365:883-891.
Giugliano RP, et al. Edoxaban versus warfarin in patients with atrial fibrillation. New Engl J Med 2013; 369:2093-2104.