Patient Education Blog

Posts Tagged ‘warfarin’

Antiphospholipid Syndrome: Can the New Oral Blood Thinners Be Used?

| Anticoagulants, Antiphospholipid antibodies, Deep vein thrombosis (DVT), Edoxaban, Eliquis, Eliquis - Apixaban, Pradaxa - dabigatran, Pulmonary embolism, Savaysa - Edoxaban, Venous clots, Xarelto - Rivaroxaban | Comments Off on Antiphospholipid Syndrome: Can the New Oral Blood Thinners Be Used?

Stephan Moll, MD and Damon Houghton, MD write … Antiphospholipid syndrome (APS) is an acquired clotting disorder.  Patients with APS may have DVT or PE that requires treatment with blood thinners. Warfarin (Coumadin®, Jantoven®), and sometimes the injectable heparin drugs (enoxaparin = Lovenox®; dalteparin = Fragmin®; tinzaparin = Innohep®; etc.), have traditionally been used in patients with APS.  A question that comes up is whether one of the new oral blood thinners (apixaban = Eliquis®; dabigatran = Pradaxa®; edoxaban = Savaysa®; rivaroxaban = Xarelto®) can be used instead of warfarin or a heparin drug.  These drugs are collectively referred to as direct oral anticoagulants (DOACs).

It is not known at this point whether DOACs are equally, more or less effective as/than warfarin in patients with APS.  Data from clinical trials directly comparing DOACs with warfarin are not yet available.  Given the absence of data, no formal recommendations or guidelines exist on this topic.  It is an individualized decision between a physician and patient with APS whether to use warfarin or a DOAC for the treatment of DVT or PE.

Published Data

Multiple cases of patients with APS treated with a DOAC have been published. All of these (i.e. a total of 122 patients) have recently been summarized [ref 1]: Sixteen percent (i.e. one of every 6 patients) had a recurrent clot on a DOAC.  As this is a high rate of DOAC failure, the authors caution about the use of DOACs in APS.  However, two things need to be considered: (a) it is also known that warfarin has a high failure rate [references 2,3]; and (b) due to the nature of case report publications (potential bias; absence of control group), no strong or meaningful conclusion is really possible as to how DOACs compare to warfarin in the treatment of DVT and PE in patients with APS

Ongoing Studies

Several studies on APS and the use of DOACs are ongoing.  Details of the following studies can be found at clinicaltrials.gov:

  1. NCT02157272: A Prospective, Randomized Clinical Trial Comparing Rivaroxaban with Warfarin in High Risk Patients With Antiphospholipid Syndrome (TRAPS)
  2. NCT02295475: Apixaban for the Secondary Prevention of Thromboembolism Among Patients With the AntiphosPholipid Syndrome (ASTRO-APS)
  3. NCT02116036: Rivaroxaban for Antiphospholipid Antibody Syndrome (RAPS)

Our practice

This is what we discuss with the patient with APS who needs to be on a blood thinner:

  1. I highlight that no solid data exist regarding the use of DOACs in APS, and that it is not known whether the DOACs are as effective as warfarin, less effective or more effective.
  2. I discuss the fact that some patients with APS develop new clots in spite of being on warfarin and that recurrent clots may also occur on a DOAC.

If we decide to use a DOAC, then our preference is typically to use a twice daily dosed blood thinner (Eliquis® or Pradaxa®) rather than a once daily dosed drug (Xarelto® or Savaysa®).  The thought behind this is that a twice daily dosed drug leads to more steady drug levels throughout the day and that this may lead to a more effective blood thinning effect.  However, this is a theory unproven, and whether this truly leads to a lower risk of recurrent clots than being on a once daily drug is not known.  A recent publication of a case report with discussion of drug metabolism also favors a twice daily rather than a once daily dosed drug in patients with APS [ref 4].  Ultimately, the most effective medication is likely the one that is taken as prescribed; therefore, a patient’s preference regarding the feasibility and practicality of a once daily versus twice daily medication is also an important consideration.

References

  1. Dufrost V et al. Direct oral anticoagulants use in antiphospholipid syndrome: Are these drugs an effective and safe alternative to warfarin? A systematic review of the literature. Curr Rheumatol Rep 2016;18:74.
  2. Crowther M et al. A Comparison of two intensities of warfarin for the prevention of recurrent thrombosis in patients with the antiphospholipid antibody syndrome. N Engl J Med 2003;349:1133-8.
  3. Finazzi G et al. A randomized clinical trial of high-intensity warfarin vs. conventional antithrombotic therapy for the prevention of recurrent thrombosis in patients with the antiphospholipid syndrome (WAPS) J Thromb Haemost 2005;3: 848–853.
  4. Schofield JR et al. Dosing considerations in the use of the direct oral anticoagulants in the antiphospholipid syndrome. J Clin Pharm Ther. 2017 Jun 27. doi: 10.1111/jcpt.12582. [Epub ahead of print].

 

Disclosure: Dr. Moll has consulted for Janssen Pharmaceuticals and Boehringer-Ingelheim. Dr. Houghton has no disclosures.

Last updated: July 5th, 2017

Eliquis (Apixaban) FDA-Approved for DVT and PE Treatment

| Blood thinners (anticoagulants), Eliquis - Apixaban, Pradaxa - dabigatran, warfarin / coumadin, Xarelto - Rivaroxaban | Comments Off on Eliquis (Apixaban) FDA-Approved for DVT and PE Treatment

Stephan Moll, MD writes…  Apixaban (Eliquis®) was approved by the FDA this week (Aug 21, 2014) for the treatment of DVT and PE.  The approval covers (a) acute DVT/PE management and (b) the longer-term prevention of recurrent DVT/PE. Read the rest of this entry »

Major Bleeding on Pradaxa (Dabigatran) – Interesting Publication

| Bleeding, Blood thinners (anticoagulants), Pradaxa - dabigatran, Therapy | Comments Off on Major Bleeding on Pradaxa (Dabigatran) – Interesting Publication

Stephan Moll, MD writes…

Interesting publication this week in Circulation: “Management and outcomes of major bleeding during treatment with dabigatran or warfarin” (Majeed A et al; published online Sept 30,2013; full publication is here). The management and prognosis of major bleeding in patients treated with dabigatran or warfarin was compared, pooling data of the major bleeds that occurred in 5 phase III dabigatran trials. 1,121 major bleeds occurred in 27,419 patients treated with warfarin or dabigatran. Read the rest of this entry »

Testing for Clotting Disorders – Can It Be Done While on Blood Thinners?

| Acquired risk factors, Antiphospholipid antibodies, Antithrombin deficiency, APC resistance, Clotting disorder - thrombophilia, Factor V Leiden, Inherited (genetic), Protein C deficiency, Protein S deficiency, Prothrombin 20210 mutation | Comments Off on Testing for Clotting Disorders – Can It Be Done While on Blood Thinners?

Stephan Moll, MD writes…  The decision how long to treat a patient who has had a DVT or PE with blood thinners can often be made based just on the patient’s history. Often no testing for clotting disorders (thrombophilias) is needed.  The decision how long to treat is influenced by 3 factors: (1) What is the person’s risk of another clot if he/she is not on blood thinners any more? (2) What is the person’s risk for bleeding on blood thinners? (3) What is the person’s own preference regarding his/her treatment. These issues are discussed in detail here.

However, if one were to do testing, what is the  right time to test? It is important to know that some blood thinners can influence test results.

Read the rest of this entry »

Use of Xarelto (Rivaroxaban) in Pulmonary Embolism

| Uncategorized, Xarelto - Rivaroxaban | Comments Off on Use of Xarelto (Rivaroxaban) in Pulmonary Embolism

Stephan Moll, MD writes…

The large clinical trial comparing  Xarelto (Rivaroxaban) with warfarin in the treatment of patients with newly diagnosed pulmonary embolism (PE) was published in the New England Journal of Medicine March 26th, 2012, showing that Xarelto was (a) as effective as warfarin in preventing new clots, (b) caused the same amount of overall clinically relevant bleeding, and (c) caused less major bleeding. Read the rest of this entry »

INR Self-Testing

| INR, warfarin / coumadin | Comments Off on INR Self-Testing

Stephan Moll, MD writes…


INR home testing devices are available to patients. They are often reimbursable by insurance carriers.  Warfarin management through patient self-testing at home is at least as effective and safe as INR testing through a physician’s office or a warfarin clinic, if patients are well-selected.  The well-done large THINRS trial published in 2010 clearly showed this, and a 2011 systematic review of the medical literature confirmed that Read the rest of this entry »