Key result
DOAC lead-in for acute VTE linked to ~74% lower recurrence and major bleeding versus parenteral.
Why the study?
Although not recommended, parenteral anticoagulation is often used instead of apixaban or rivaroxaban lead-in dosing for initial VTE treatment, prompting an evaluation of their comparative safety and effectiveness.
Does DOAC lead-in dosing reduce VTE recurrence and major bleeding compared to parenteral lead-in dosing in adult patients with acute VTE treated with apixaban or rivaroxaban?
Cohort (n=389)
Yes
Does DOAC lead-in dosing reduce VTE recurrence and major bleeding compared to parenteral lead-in dosing in adult patients with acute VTE treated with apixaban or rivaroxaban?
Absolute Event Rate: 1.4% vs 5.4%
p-value: p=0.039
In patients treated with apixaban or rivaroxaban for acute VTE, using a parenteral lead-in instead of the recommended DOAC lead-in dosing is associated with significantly higher rates of major bleeding and 90-day VTE recurrence.
Should not yet change VTE lead-in practice; hypothesis-generating for DOAC versus parenteral regimens.
Background: Although parenteral anticoagulation lead-in is not recommended with apixaban and rivaroxaban, parenteral anticoagulation is often used to replace apixaban or rivaroxaban lead-in doses for the initial phase treatment of VTE. Thus, our study compares the safety and effectiveness of lead-in parenteral anticoagulation to lead-in apixaban or rivaroxaban in patients who received apixaban or rivaroxaban for VTE treatment. Methods: A multi-center retrospective cohort study included adult patients (aged ≥ 18 years) admitted to the hospital with acute VTE and treated with either apixaban or rivaroxaban. Patients were grouped depending on the lead-in anticoagulation received for initial VTE treatment into the “Direct oral anticoagulation (DOAC) lead-in” group if patients received an appropriate lead-in dose of apixaban and rivaroxaban and patients who received parenteral lead-in the “parenteral lead-in” group. Results: A total of 389 patients were included; the DOAC lead-in group included 296 patients, whereas 93 patients were in the parenteral lead-in group. VTE recurrence (rVTE) during hospitalization and within 30 days was numerically higher in the parenteral lead-in group compared to the DOAC lead-in group (3.3% vs 0.6%; p =0.09 and 1.1% vs 0.7%; p =0.560), with a significantly higher number of patients with rVTE at 90 days (5.4% vs 1.4%; p =0.039). However, none of the patient’s characteristics were significantly associated with the incidence of rVTE. In addition, the major bleeding rate during hospitalization was significantly higher among the parenteral lead-in group than in the DOAC lead-in group (14.0% vs 3.7%; p < 0.001). Conclusion: Parenteral anticoagulation lead-in before starting maintenance of apixaban and rivaroxaban showed a significantly higher risk of bleeding and a trend toward higher VTE recurrence than the DOAC lead-in. This study adds to the evidence supporting the utilization of the DOAC lead-in regimen in treating patients with VTE. Still, larger studies with robust designs are needed to confirm these findings.
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Korayem et al. (2023) conducted a cohort in Acute venous thromboembolism (VTE) (n=389). Direct oral anticoagulation (DOAC) lead-in (apixaban or rivaroxaban) vs. Parenteral lead-in was evaluated on VTE recurrence at 90 days (p=0.039). DOAC lead-in for acute VTE was associated with lower VTE recurrence at 90 days (1.4% vs 5.4%; p=0.039) and major bleeding (3.7% vs 14.0%; p<0.001) compared to parenteral lead-in.
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