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Results mixed on rivaroxaban for extended thromboprophylaxis in MARINER
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MUNICH — In medically ill patients at risk for venous thromboembolism, rivaroxaban did not improve the composite endpoint of symptomatic VTE or death due to VTE, according to the results of the MARINER study.
However, rivaroxaban (Xarelto, Janssen) was superior to placebo in reducing symptomatic VTE alone, and bleeding rates were low, researchers reported at the European Society of Cardiology Congress.
“There’s a very large unmet medical need in acutely medically ill patients, especially in the post-discharge period,” Alex C. Spyropoulos, MD, professor of medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and professor at the Feinstein Institute for Medical Research, told Cardiology Today. “The standard of care … is actually doing nothing. Less than 1% of these patients get anything in terms of post-discharge prophylaxis. Yet, about 80% of VTE events in this population occur in the post-discharge period.”
He noted this population, which includes patients with HF, stroke, inflammatory diseases and other conditions, tends to experience worse VTE events than the surgical population due to being older, having more comorbidities and having limited cardiopulmonary reserve.
Spyropoulos and colleagues randomly assigned 12,024 medically ill patients at elevated risk for VTE based on an IMPROVE score of 4 or higher or a score of 2 or 3 if they also had a plasma D-dimer level more than twice the upper limit of normal to receive rivaroxaban 10 mg daily (adjusted to 7.5 mg per day for moderate renal insufficiency if necessary) or placebo for 45 days. Patients were followed for 30 days after the 45-day period.
The primary endpoint was symptomatic VTE or VTE-related death. The key secondary endpoint was nonfatal symptomatic VTE. The key safety endpoint was major bleeding.
There was no significant difference in the primary endpoint in the intention-to-treat population (rivaroxaban group, 0.83%; placebo group, 1.1%; HR = 0.76; 95% CI, 0.52-1.09), according to the researchers.
However, nonfatal symptomatic VTE was lower in the rivaroxaban group (0.18% vs. 0.42%; HR = 0.44; 95% CI, 0.22-0.89), Spyropoulos said.
Major bleeding rates were low and did not significantly differ between the groups (rivaroxaban group, 0.28%; placebo group, 0.15%; HR = 1.88; 95% CI, 0.84-4.23), according to the researchers.
In addition, Spyropoulos said, the rivaroxaban group had a 27% reduction in symptomatic VTE and all-cause mortality (HR = 0.73; 95% CI, 0.54-0.97).
The treatment effect for the primary outcome was stronger among those given the 10-mg dose of rivaroxaban vs. the 7.5-mg dose; during a press conference, Spyropoulos said there was “no future” for the 7.5-mg dose in this population.
“We achieved reductions in two important secondary outcomes, which should be considered exploratory,” Spyropoulos said in an interview. “These, combined with the low rates of bleeding, show that the strategy is very safe. If one is able to identify the appropriate patients, such as was done with the individualized approach in MARINER, especially in the U.S. hospital system with shorter lengths of stay, we could expect a reduction in symptomatic VTE, about half of which are nonfatal pulmonary emboli. Even though the absolute risk difference was small, we probably could save about 10,000 nonfatal PEs in the U.S. and European Union annually at the cost of one-tenth of that number of fatal or critical bleeds.”
The data were simultaneously published in The New England Journal of Medicine. – by Erik Swain
References:
Spyropoulos AC, et al. Hot Line Session 1. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.
Spyropoulos AC, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1805090.
Disclosures: The study was funded by Janssen. Spyropoulos reports he consults for Boehringer Ingelheim, Janssen and Portola. Please see the study for a list of the other authors’ relevant financial disclosures.
Perspective
Back to TopHeinz Drexel, MD
This trial is an example of how we do so many good things in prevention. We are aware of the signs of PE, so we are better at preventing and treating it. Therefore, it becomes more difficult to show a benefit of 6 weeks of rivaroxaban treatment after discharge. It is open to question as to whether this is a sufficiently good result. It appears the question is not answered yet. There is a point where some patients benefit.
A patient-centered approach should hold sway. If you know you have someone who is medically ill who has had problems with their veins before, you may want to prescribe rivaroxaban for that patient. But if the patient had the flu and then is completely healthy afterwards, it is probably not worthwhile to prescribe 6 weeks of anticoagulant therapy.
Perspective
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Ileana L. Piña, MD, MPH
Extended VTE prophylaxis with an anticoagulant is not something we do routinely. We know that there is a “perilous time” after discharge during which patients, especially those with HF, are likely to get sick again. Mobility helps avoid this, and I worry about immobility if the patient is prescribed a drug like rivaroxaban. At least rivaroxaban was not harmful. I was pleased at the safety results, because when patients on oral anticoagulants bleed, they bleed profusely.
However, rivaroxaban is expensive, and now more money has to be spent on another drug as a patient leaves the hospital. We have found that these types of patients leave the hospital with 13 drugs, between the ones they were taking before and the ones prescribed during their stay and at discharge. When we see a patient for the first time in our post-discharge clinic, we get rid of what I call “the junk”: the stool softener, the laxative, the sleeping pill and the pain pill. Now we want to add one more? For our patients with left ventricular assist devices, insurers often object when we try to switch them from warfarin to enoxaparin (Lovenox, Sanofi), much less one of the newer anticoagulants.
I think this should be mentioned in the guidelines as something possibly not to do because there is not strong evidence.
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