Cadth 2015 e5 ad panel discussion af
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Cadth 2015 e5 ad panel discussion af
- 1. Atrial Fibrillation Stroke Prevention with Oral Anticoagulants Why is there discordance between guideline committees & specialists when the data is based on the same 3 landmark trials?
- 3. January 2013
- 4. April 2015
- 5. CCS AF Guidelines • 2010: • Dabigatran preferred over warfarin (Conditional Recommendation, High-Quality Evidence). • 2012: • NOAC preferred over warfarin (note: apixaban - when approved by Health Canada) (Conditional Recommendation, High-Quality Evidence) • 2014: • NOAC preferred over warfarin (note: edoxaban when approved by Health Canada) (Strong Recommendation, High Quality Evidence) – High value: greater efficacy of dabigatran during a relatively short time of follow-up, lower incidence of intracranial hemorrhage; ease of use – Less value: long safety experience with warfarin – High value: greater/similar efficacy, less/same major bleeds, less intracranial bleeds, easier to use – Less value: long experience with clinical use, antidote, simple/standardized test (i.e. INR) – High value: greater ease of use, superior/non-inferior, no more/less major bleeding especially less intracranial – Less value: shorter clinical experience, lack of antidote, lack of simple test for intensity of anticoagulant effect
- 6. CCS AF Guidelines GRADE
- 7. 2014 Guidelines AHA/ASA 2014 Stroke Prevention Guidelines • Prevention of recurrent stroke in patients with non- valvular AF: • Warfarin or Apixaban (1A) • Dabigatran (IB) • Rivaroxban (IIaB) AHA/ACC/HRS 2014 AF Guidelines • Prior stroke/TIA or CHA2DS2-VASc score ≥2: • Warfarin (1A) • Apixaban, dabigatran, rivaroxaban (1B)
- 9. 2014 Guidelines AHA/ASA 2014 Stroke Prevention Guidelines • Prevention of recurrent stroke in patients with non- valvular AF: • Warfarin or Apixaban (1A) AVVEROES, ARISTOTLE • Dabigatran (IB) RELY • Rivaroxban (IIaB) ROCKET AHA/ACC/HRS 2014 AF Guidelines • Prior stroke/TIA or CHA2DS2-VASc score ≥2: • Warfarin (1A) • Apixaban, dabigatran, rivaroxaban (1B) • ARISTOTLE, RELY, ROCKET AVVEROES -Patients deemed unsuitable for VKA - Apixiban 5mg po BID vs ASA
- 12. • Why is there discordance between guideline committees & specialists when the data is based on the same 3 landmark trials? • Values influence guideline committees and prescribing. • Patient values need to be considered as well; shared decision making. • Tailor therapy to individual patients.
Hinweis der Redaktion
- RxFiles – AF selected as the academic detailing topic for the winter/spring 2013 topic Dabigatran & rivaroxaban were listed on the SK Drug Formulary with Exceptional Drug Status criteria to meet. Apixaban was approved by Health Canada for stroke prevention in non-valvular AF December 2012. We included all three NOACs in our materials. A number of guidelines were reviewed for the topic, including the relevant landmark trials, etc.
- Will let Cait address “High-quality evidence”.
- Do not plan on going into detail with the following: CADTH: since Sarah will address CHEST/ACCP 2012 Guidelines: as only addressed dabigatran & are outdated
- Double check with Sarah if okay
- Back in 2012-13 Cardiologist & neurologist: NOAC (superior & non-inferior for preventing stroke & systemic embolism) Nephrologist: warfarin (NOACs used/dosed inappropriately in renal dysfunction) Hematologist: warfarin when it works, NOAC in those who are not appropriate for warfarin Hematopathologist: if going to use a NOAC, ensure plan in place for potential bleeding ER Physician: warfarin (now how to reverse a warfarin bleed, how the @#!% do I reverse a NOAC bleed) Gastroenterologist: warfarin (dabigatran 150mg BID & rivaroxaban cause more GI bleeding) Internist: warfarin… when managed appropriately Family physician: what the heck are we supposed to do?!