Dr Steven Deitelzweig: Switching From Apixaban to Rivaroxaban Linked to Increased Risks for Patients With NVAF

According to Steven Deitelzweig, MD, system chairman of hospital medicine at Ochsner Clinical School, professor of medicine at the University of Queensland, switching from apixaban to rivaroxaban was linked to a higher risk of stroke/systemic embolism and major bleeding compared with apixaban continuation, among patients with nonvalvular atrial fibrillation (NVAF). These findings were presented at the European Society of Cardiology (ESC) Congress 2023.

Transcript

What were some of your main findings surrounding switching or continuation of apixaban or rivaroxaban among patients with NVAF?

We see in the clinical trials that we've looked at, varying studies with different outcomes, you can get the DOACs [direct oral anticoagulants] with nonvalvular atrial fibrillation, but what we've come to realize in the real world, there's a lot of switching that's happening, whether it's for medical reasons or nonmedical reasons, like insurance-based reasons. So, we looked at both ways—folks who switched from apixaban to rivaroxaban, or folks that switched from rivaroxaban to apixaban—and we compared those as switchers vs continuers.

In the patients that were switched from apixaban to rivaroxaban, that was associated with a higher risk of stroke/systemic embolism and major bleeding, with a pretty impressive hazard ratio of 1.99 and 1.80, respectively, and that was in comparison to folks that were continuers of apixaban. On the other side, when we compared folks that went from rivaroxaban to apixaban, it was associated with comparable or similar associated risk of stroke and systemic embolism with a hazard ratio of 0.74 but lower major bleeding, with a hazard ratio of 0.49 in comparison to folks that stayed on rivaroxaban. That's what we found.

So, at the end of the time, when we looked at switchers and continuers, we saw that the safety side for patients was really befalling apixaban, similar to what we had seen with either other real-world evidence or some of the clinical trials.

Given these findings, what advice would you give to cardiologists who have patients looking to switch treatment?

The way I view it is, because the switch could happen for medical or nonmedical reasons, if it's happening for nonmedical reasons, I would want the cardiologist to be active and advocate for patients. That's what we should be doing any and all times, advocate for our patients. So, if you're not comfortable with the switch, appeal, fight, do whatever is needed to do for your patients. If you're dealing with a switch for a medical reason, maybe it's a different circumstance, and you just need to individualize it to your patient.

How does your recent research on Medicare beneficiaries continuing apixaban add context to these findings?

We always have to take any of the real-world evidence in context. The way I would view this in context is that it's not just stroke/systemic embolism and major bleeding. That's very important, because that has a lot of population and real personal cost, not financial costs, but clinical costs. So, I put it all in that context. Look at age, we've cut the data. We had another publication, ARISTOPHANES, where we cut it by frailty, we cut it by age, we cut it by kidney disease, you can cut it by obesity, all the other comorbid states that do exist. So this is one more input for decision making.