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Real world prescribing practices of apixaban or rivaroxaban lead-in doses for the treatment of venous thromboembolism in hospitalized patients

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Abstract

The oral factor Xa inhibitors (OFXAi) apixaban and rivaroxaban are increasingly utilized for the treatment of venous thromboembolism (VTE) with recommended initial higher dose 7- and 21-day lead-in regimens, respectively. In patients receiving initial parenteral anticoagulation, it remains unknown if the full recommended higher dose OFXAi lead-in regimens are warranted, or if days can be subtracted. We aimed to describe when clinicians may deviate from recommended lead-in durations and evaluate clinical outcomes in these scenarios. This is a retrospective, observational study of patients 18 years or older who were treated with rivaroxaban or apixaban for acute pulmonary embolism (PE) or symptomatic proximal deep vein thrombosis (DVT) that received parenteral anticoagulation for at least 24 h before transitioning to the OFXAi. Among our cohort of 171 patients with acute VTE who received parenteral anticoagulation for a median of 48 h, 134 (78%) were prescribed a full OFXAi lead-in and 37 (22%) were prescribed a reduced lead-in. Patients in the reduced lead-in group were older with more cardiac comorbidities and antiplatelet use. There were four recurrent thromboembolic events within 3 months, two in the reduced lead-in group and two in the full lead-in group (5% vs. 2%, p = 0.206). Bleeding within 3 months occurred in 9 (5%) patients, with 6 events occurring in the reduced lead-in group and 3 events in the full lead-in group (16% vs. 2%, p = 0.004). Prescribing patterns of OFXAi lead-in therapy duration are variable in patients receiving initial parenteral anticoagulation. Larger cohorts are needed to better define the safety and efficacy of lead-in reduction.

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Acknowledgements

All authors have fulfilled the conditions required for authorship. MW performed research, analyzed and interpreted data, and wrote the first draft of the manuscript. TA designed research, interpreted data and provided review and oversight of the research and the manuscript. VR designed research, interpreted data and provided reviews of the manuscript. JP interpreted data and provided reviews of the manuscript. EY interpreted data and provided reviews of the manuscript. DG interpreted data and provided review of the manuscript. SA designed research, interpreted data and provided reviews of the manuscript. All authors were responsible for and approved the final version of the manuscript.

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The authors received no financial support for the research, authorship, and/or publication of this article.

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Authors and Affiliations

  1. Department of Pharmacy, NYU Langone, New York, NY, 10016, USA

    Matthew Williams, Tania Ahuja, John Papadopoulos & Serena Arnouk

  2. Department of Pharmacy, NYU Langone, Brooklyn, NY, 11209, USA

    Veronica Raco

  3. Division of Hematology, Department of Medicine, NYU Langone, New York, NY, USA

    David Green

  4. Division of Cardiology, Department of Medicine, NYU Langone, New York, NY, 10016, USA

    Eugene Yuriditsky

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  1. Matthew Williams
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  2. Tania Ahuja
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Correspondence to Tania Ahuja.

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Williams, M., Ahuja, T., Raco, V. et al. Real world prescribing practices of apixaban or rivaroxaban lead-in doses for the treatment of venous thromboembolism in hospitalized patients. J Thromb Thrombolysis 54, 219–229 (2022). https://doi.org/10.1007/s11239-022-02641-5

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