Rivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome: A Randomized Noninferiority Trial
- PMID: 31610549
- DOI: 10.7326/M19-0291
Rivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome: A Randomized Noninferiority Trial
Abstract
Background: The potential role of new oral anticoagulants in antiphospholipid antibody syndrome (APS) remains uncertain.
Objective: To determine whether rivaroxaban is noninferior to dose-adjusted vitamin K antagonists (VKAs) for thrombotic APS.
Design: 3-year, open-label, randomized noninferiority trial. (EU Clinical Trials Register: EUDRA [European Union Drug Regulatory Authorities] code 2010-019764-36).
Setting: 6 university hospitals in Spain.
Participants: 190 adults (aged 18 to 75 years) with thrombotic APS.
Intervention: Rivaroxaban (20 mg/d or 15 mg/d, according to renal function) versus dose-adjusted VKAs (target international normalized ratio, 2.0 to 3.0, or 3.1 to 4.0 in patients with a history of recurrent thrombosis).
Measurements: The primary efficacy outcome was the proportion of patients with new thrombotic events; the primary safety outcome was major bleeding. The prespecified noninferiority margin for risk ratio (RR) was 1.40. Secondary outcomes included time to thrombosis, type of thrombosis, changes in biomarker levels, cardiovascular death, and nonmajor bleeding.
Results: After 3 years of follow-up, recurrent thrombosis occurred in 11 patients (11.6%) in the rivaroxaban group and 6 (6.3%) in the VKA group (RR in the rivaroxaban group, 1.83 [95% CI, 0.71 to 4.76]). Stroke occurred more commonly in patients receiving rivaroxaban (9 events) than in those receiving VKAs (0 events) (corrected RR, 19.00 [CI, 1.12 to 321.9]). Major bleeding occurred in 6 patients (6.3%) in the rivaroxaban group and 7 (7.4%) in the VKA group (RR, 0.86 [CI, 0.30 to 2.46]). Post hoc analysis suggested an increased risk for recurrent thrombosis in rivaroxaban-treated patients with previous arterial thrombosis, livedo racemosa, or APS-related cardiac valvular disease.
Limitation: Anticoagulation intensity was not measured in the rivaroxaban group.
Conclusion: Rivaroxaban did not show noninferiority to dose-adjusted VKAs for thrombotic APS and, in fact, showed a non-statistically significant near doubling of the risk for recurrent thrombosis.
Primary funding source: Bayer Hispania.
Comment in
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Direct Oral Anticoagulants in Antiphospholipid Syndrome: Too Early or Too Late?Ann Intern Med. 2019 Nov 19;171(10):765-766. doi: 10.7326/M19-2815. Epub 2019 Oct 15. Ann Intern Med. 2019. PMID: 31610546 No abstract available.
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End of the road for direct oral anticoagulants in thrombotic APS?Nat Rev Rheumatol. 2019 Dec;15(12):697. doi: 10.1038/s41584-019-0335-2. Nat Rev Rheumatol. 2019. PMID: 31685956 No abstract available.
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Rivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome.Ann Intern Med. 2020 Apr 7;172(7):509-510. doi: 10.7326/L20-0052. Ann Intern Med. 2020. PMID: 32252074 No abstract available.
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Rivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome.Ann Intern Med. 2020 Apr 7;172(7):510. doi: 10.7326/L20-0053. Ann Intern Med. 2020. PMID: 32252075 No abstract available.
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Rivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome.Ann Intern Med. 2020 Sep 15;173(6):505-506. doi: 10.7326/L20-0054. Ann Intern Med. 2020. PMID: 32926827 No abstract available.
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Direct oral anticoagulant use in patients with antiphospholipid syndrome and unprovoked venous thromboembolism: a single centre experience.Br J Haematol. 2021 Oct;195(2):276-278. doi: 10.1111/bjh.17634. Epub 2021 Jul 6. Br J Haematol. 2021. PMID: 34231202 No abstract available.
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