Non-valvular atrial fibrillation: impact of apixaban on patient outcomes

Abstract

Atrial fibrillation is the most common arrhythmia worldwide, and carries a significantly increased risk of thromboembolic stroke. Initially, vitamin K antagonists were used as stroke prophylaxis; but more recently, a group of drugs known as novel oral anticoagulants have been developed. Apixaban belongs to this group of drugs, and is a factor Xa inhibitor that has emerged as a popular pharmacological agent worldwide. In this review, we will provide an overview of the pivotal trials in the development of apixaban, while also critically evaluating the new emerging real-world data, and discussing the effectiveness, safety, economic viability and future prospects of apixaban and how it impacts on patient outcomes in those with non-valvular atrial fibrillation.

Impact of direct oral anticoagulant off‐label doses on clinical outcomes of atrial fibrillation patients: A systematic review

“…Furthermore, studies suggested that off‐label underdosing of apixaban without following the dose‐reduction criteria is associated with a nearly 5‐fold increased risk of stroke . An important result from Ioannou et al is that using a reduced dose of apixaban in patients with normal renal function and younger than 75 years was associated with 50% lower plasma concentrations than when treated with standard dose. This can lead to subtherapeutic apixaban plasma levels and predisposes those patients to a higher risk of developing thromboembolic events.…”

“…However, this can be explained, in part, by clinicians not always prescribing according to the guidelines, introducing this reduced‐dose regimen in patients who should be receiving the standard dose. Therefore, these patients become unintentionally undertreated, which increases their risk of thromboembolic complications . Underdosing may have important implications, as rates of systemic embolism, stroke, major bleeding and mortality are generally higher for patients receiving the lower vs higher DOAC dose .…”

“…Therefore, these patients become unintentionally undertreated, which increases their risk of thromboembolic complications. 82 Underdosing may have important implications, as rates of systemic embolism, stroke, major bleeding and mortality are generally higher for patients receiving the lower vs higher DOAC dose. 39 However, some studies suggest that, in the future, suboptimal low-dose DOAC therapy may serve as an appropriate choice for some patients with a high risk of stroke and bleeding.…”

Off‐label underdosing of four individual NOACs in patients with nonvalvular atrial fibrillation: A systematic review and meta‐analysis of observational studies

“…It is probably because off-label underdosing of apixaban may lead to subtherapeutic plasma level of apixaban, potentially resulting in a higher incidence of subclinical stroke and long-term mortality. 31 As such, the description of the off-label underdose of apixaban should not be in the recommendation. When patients are not up to the standard of on-label reduced dose, sticking to the on-label dose of apixaban would let patients benefit more from it.…”

Special Issue “Cardiovascular Genetics”

“…In contrast to monogenic inherited cardiomyopathies, AF is a complex heart rhythm disorder caused by environmental and multi-genic risk factors [ 39 ] and significantly increases the risk for stroke and heart failure. Apixaban is an anticoagulant drug used to reduce the risk for stroke in patients with non-valvular AF [ 40 ]. The work of Rosian et al showed that there was no significant association between peak apixaban plasma concentrations in patients with specific SNPs in the ABCB1 gene, encoding an ATP-binding cassette (ABC) transporter [ 41 ].…”