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Apixiban Dosing to Optimize Protection from Thrombosis

Mary Cushman, MD, MSc University of Vermont. Apixiban Dosing to Optimize Protection from Thrombosis. Prophylaxis in Medical Inpatients: What is the Problem?. Incidence rate (symptomatic): 1% ½ occur after discharge We don’t understand which patients are at highest risk.

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Apixiban Dosing to Optimize Protection from Thrombosis

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  1. Mary Cushman, MD, MSc University of Vermont Apixiban Dosing to Optimize Protection from Thrombosis

  2. Prophylaxis in Medical Inpatients: What is the Problem? • Incidence rate (symptomatic): 1% • ½ occur after discharge • We don’t understand which patients are at highest risk

  3. ACP Guidelines 2011 • Assess risk of thrombosis and bleeding • Prophylaxis in those at high thrombosis risk unless high bleeding risk • Decreases PE by 4 events per 1000 treated • Increases major bleeding by 1 per 1000 treated • No universal prophylaxis Qaseem A. Annals Intern Med 2011

  4. What is a High Risk Medical Patient? • Most existing scores developed empirically • None well validated Kucher, NEJM 2005; Barbar, JTH 2010; Spyropoulos, Chest, 2011 • Hospitalized patients ≠ general population • Older age, obesity: NO • Trauma, pneumonia, platelets, some cancers: YES Zakai NA, JTH 2004

  5. ADOPT Inclusion Criteria Hospitalized with: • CHF or Respiratory Failure • Infection, Acute Rheumatic Disorder or IBD + ≥ 1 of: • Age ≥ 75, prior VTE, BMI ≥30, estrogen therapy • Mobility restricted to walking in room

  6. ADOPT % with VTE 2.6-fold increased risk of major bleeding

  7. Drawbacks of Many Trials • Most rely on screen-detected DVT so serious VTE minimized • Treatment not extended after discharge • Risk extends 3 months • ½ of events after discharge • Follow up not long enough to detect VTE occurring after therapy

  8. Future Directions • Develop validated risk models to include only high risk patients in trials • Use treatment with lowest bleeding risk • Continue follow up after treatment • More study of post-discharge treatment

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