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Sulaiman KA, Aljuhani O, Alkofide H, Aljohani MA, Badreldin HA, Al Harbi M, Aquil G, Alhajaji R, Alqahtani RA, Babonji A, Altuwayr M, Alshehri AA, Alfaifi M, Alharthi AF, Alzahrani M, Al Sulaiman T, Alqahtani N, Alshahrani WA, Al Katheri A, Albekairy AM. Evaluation of Apixaban standard dosing in underweight patients with non-valvular atrial fibrillation: a retrospective cohort study. Thromb J 2024; 22:43. [PMID: 38778323 PMCID: PMC11110266 DOI: 10.1186/s12959-024-00613-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Recent guidelines recommend using direct oral anticoagulants (DOACs) as first-line agents in patients with non-valvular atrial fibrillation (NVAF). Research is currently investigating the use of Apixaban in underweight patients, with some results suggesting altered pharmacokinetics, decreased drug absorption, and potential overdosing in this population. This study examined the effectiveness and safety of standard Apixaban dosing in adult patients with atrial NVAF weighing less than 50 kg. METHODS This is a retrospective cohort study conducted at King Abdulaziz Medical City (KAMC); adult patients with a body mass index (BMI) below 25 who received a standard dose of Apixaban (5 mg twice daily) were categorized into two sub-cohorts based on their weight at the time of Apixaban initiation. Underweight was defined as patients weighing ≤ 50 kg, while the control group (Normal weight) comprised patients weighing > 50 kg. We followed the patients for at least one year after Apixaban initiation. The study's primary outcome was the incidence of stroke events, while secondary outcomes included bleeding (major or minor), thrombosis, and venous thromboembolism (VTE). Propensity score (PS) matching with a 1:1 ratio was used based on predefined criteria and regression model was utilized as appropriate. RESULTS A total of 1,433 patients were screened; of those, 277 were included according to the eligibility criteria. The incidence of stroke events was lower in the underweight than in the normal weight group at crude analysis (0% vs. 9.1%) p-value = 0.06), as well in regression analysis (OR (95%CI): 0.08 (0.001, 0.76), p-value = 0.002). On the other hand, there were no statistically significant differences between the two groups in the odds of major and minor bleeding (OR (95%CI): 0.39 (0.07, 2.03), p-value = 0.26 and OR (95%CI): 1.27 (0.56, 2.84), p-value = 0.40, respectively). CONCLUSION This exploratory study revealed that underweight patients with NVAF who received standard doses of Apixaban had fewer stroke events compared to normal-weight patients, without statistically significant differences in bleeding events. To confirm these findings, further randomized controlled trials with larger sample sizes and longer observation durations are required.
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Affiliation(s)
- Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia.
- Saudi Society for Multidisciplinary Research Development and Education (SCAPE Society), Riyadh, Saudi Arabia.
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hadeel Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Drug Regulation Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Manal A Aljohani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hisham A Badreldin
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mahasen Al Harbi
- Pharmaceutical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Ghalia Aquil
- Pharmaceutical Care Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Raghad Alhajaji
- Public Health Department, Makkah Health Affairs, Makkah, Saudi Arabia
- Primary Health Department, Makkah Health Cluster, Makkah, Saudi Arabia
| | - Rahaf A Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Alaa Babonji
- Pharmaceutical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | | | - Asma A Alshehri
- Pharmaceutical care departments, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mashael Alfaifi
- Pharmaceutical Services Administration, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Mohammed Alzahrani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Tareq Al Sulaiman
- Department of Orthopedic Surgery, Imam Abdulrahman Al Faisal Hospital, Riyadh, Saudi Arabia
| | | | - Walaa A Alshahrani
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
| | - Abdulmalik Al Katheri
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulkareem M Albekairy
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Akao M, Yamashita T, Fukuzawa M, Hayashi T, Okumura K. Efficacy and Safety of Low-Dose Edoxaban by Body Weight in Very Elderly Patients With Atrial Fibrillation: A Subanalysis of the Randomized ELDERCARE-AF Trial. J Am Heart Assoc 2024; 13:e031506. [PMID: 38240204 PMCID: PMC11056111 DOI: 10.1161/jaha.123.031506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/30/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND The ELDERCARE-AF trial showed that low-dose edoxaban benefits elderly patients with nonvalvular atrial fibrillation considered ineligible for standard oral anticoagulants due to high bleeding risk, but whether this applied to patients with extremely low body weight was unclear. METHODS AND RESULTS This was a prespecified subanalysis by body weight (≤45, >45 kg) of the phase 3, multicenter, randomized, double-blind, placebo-controlled, event-driven ELDERCARE-AF trial, which compared low-dose edoxaban (15 mg once daily) with placebo in Japanese patients considered ineligible for oral anticoagulants at the recommended therapeutic strength or the approved doses. The primary efficacy and safety end points were stroke or systemic embolism and major bleeding (International Society on Thrombosis and Hemostasis definition), respectively. The ≤45-kg weight group included 374/984 patients (38.0%), and the >45-kg group included 610/984 patients (62.0%). The stroke or systemic embolism rate was lower with edoxaban than placebo in both weight groups (≤45 kg: hazard ratio [HR], 0.36 [95% CI, 0.16-0.80]; >45 kg: HR, 0.31 [95% CI, 0.13-0.73]; interaction P=0.82). Major bleeding incidence was numerically higher with edoxaban than placebo (≤45 kg: HR, 3.05 [95% CI, 0.84-11.11]; >45 kg: HR, 1.40 [95% CI, 0.56-3.48), with no interaction with body weight (interaction P=0.33). All-cause mortality was higher in the ≤45-kg group, with no significant difference between treatment groups. CONCLUSIONS The benefit of edoxaban 15 mg was consistent in elderly patients with atrial fibrillation and extremely low body weight, though clinicians must remain vigilant about the risk of major bleeding, especially gastrointestinal bleeding. REGISTRATION INFORMATION ClinicalTrials.gov. Identifier: NCT02801669.
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Affiliation(s)
- Masaharu Akao
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | | | - Masayuki Fukuzawa
- Cardiovascular Group, Primary Medical Science Department, Japan Business Unit, Daiichi Sankyo Co., Ltd.TokyoJapan
| | - Takuya Hayashi
- Data Intelligence Group, Data Intelligence Department, Digital Transformation Management Division, Daiichi Sankyo Co., Ltd.TokyoJapan
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto HospitalKumamotoJapan
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Elshafei MN, Salem M, El-Bardissy A, Abdelmoneim MS, Khalil A, Elhadad S, Al Mistarihi M, Danjuma M. Comparative Effectiveness and Safety of Direct Oral Anticoagulants in Low Body Weight Patients with Atrial Fibrillation: A Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 2024:10.1007/s10557-023-07537-x. [PMID: 38165553 DOI: 10.1007/s10557-023-07537-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/04/2024]
Abstract
INTRODUCTION Direct oral anticoagulant (DOAC) agents are established as the anticoagulation strategy of choice for a variety of clinical risks. Despite this, uncertainty still exists with regard to their efficacy and safety for the prevention of stroke and systemic embolism in some patient populations; most notably those with low body weight (LBW) (<60 kg or body mass index [BMI] <18 kg/m2). Currently, there is a paucity of trial and non-trial data to support a prescriptive recommendation for their use in these patient cohorts. We have carried out a pooled systematic review of the most up to date published data of patients stabilized on various DOAC analogs with the view to ascertaining the exact matrices of their efficacy and safety in these cohorts of patients. METHODS We initially carried out a comprehensive search of databases from inception to June 2023 for eligible studies exploring the efficacy and safety of various analogs of direct oral anticoagulants in patients with atrial fibrillation who had low body weight. Databases accessed include PubMed, EMBASE, the Science Citation Index, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effectiveness. We carried out a weighted comparison of derived pooled odd ratios (with their corresponding confidence intervals) of mortality outcomes between various DOACs using the random effects model. RESULTS Thirteen studies (n = 165,205 patients) were included in our meta-analysis. DOAC analogs were associated with increased stroke-related events, composite outcome, and mortality in low body weight patients compared to non-low body weight patients (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.17-1.92), (OR 1.55, 95% CI 1.29-1.86), (OR 2.92, 95% CI 1.87-4.58), respectively. There was no significant difference in the safety outcome (major bleeding events) between the DOAC analogs (OR 1.19, 95% CI 0.93-1.52). DISCUSSION In this meta-analytical review comprising both real-world and randomized controlled studies, the use of DOAC analogs in low body weight patients (body weight of <60 kg or BMI<18 kg/m2) with atrial fibrillation was associated with increased risks of stroke-related events, composite outcomes, and mortality compared to non-low body weight cohorts patients. At the same time, there was no significant difference in terms of major bleeding events. This finding has provided the first resolution of pervading uncertainty surrounding the use of DOAC analogs in these patient cohorts and suggests the need for follow-up confirmatory systematic studies in this group of patients.
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Affiliation(s)
| | - Muhammad Salem
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed El-Bardissy
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Ahmed Khalil
- Clinical Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Mohammed Danjuma
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
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Kubota K, Ooba N. Effectiveness and Safety of Reduced and Standard Daily Doses of Direct Oral Anticoagulants in Patients with Nonvalvular Atrial Fibrillation: A Cohort Study Using National Database Representing the Japanese Population. Clin Epidemiol 2022; 14:623-639. [PMID: 35520279 PMCID: PMC9064485 DOI: 10.2147/clep.s358277] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To compare the effectiveness and safety of reduced or standard daily doses of direct oral anticoagulants (DOACs) with warfarin in Japanese patients with nonvalvular atrial fibrillation (NVAF). We used post-hoc analyses to identify patient groups that could benefit from reduced-dose DOACs. Patients and Methods Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan, we identified 944,776 patients with NVAF who had started an oral anticoagulant after at least one year of non-use between April 2011 and March 2016. We matched patients taking any, reduced, or standard doses of DOACs 1:1 with those taking warfarin. We measured treatment effectiveness based on admission due to stroke or systemic embolism (S/SE) and safety based on admission due to any bleeding (defined as major bleeding, MB). We compared both outcomes between DOACs and warfarin using the Cox proportional hazards model. We used post-hoc analysis to match patients receiving reduced-dose DOACs to those receiving standard-dose DOACs and compared treatment effectiveness and safety. Results More than half of patients receiving DOACs used a reduced dose. The occurrences of S/SE and MB in patients receiving any, reduced, or standard doses of DOACs were equal to or lower than those receiving warfarin. In the post-hoc analysis, the risk of S/SE and MB was similar between reduced and standard doses of DOACs except for those with a history of cerebral infarction and CHA2DS2-VASc score ≥3, where the risk of S/SE was lower for reduced doses of any and individual DOACs. Conclusion Findings from the current study are consistent with recent Asian and global studies but different from most studies conducted in North America and Europe, where patients receiving a reduced dose of DOACs had an increased risk of S/SE. Future studies should test the reproducibility of results from the current study.
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Affiliation(s)
- Kiyoshi Kubota
- NPO Drug Safety Research Unit Japan, Tokyo, Japan
- Department of Clinical Pharmacy, Nihon University School of Pharmacy, Funabashi, Chiba, Japan
- Correspondence: Kiyoshi Kubota, NPO Drug Safety Research Unit Japan, 6-2-9-2F Soto-Kanda, Chiyoda-ku, Tokyo, 101-0021, Japan, Tel +81-3-6284-4206, Fax +81-3-6284-4207, Email
| | - Nobuhiro Ooba
- Department of Clinical Pharmacy, Nihon University School of Pharmacy, Funabashi, Chiba, Japan
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