From the FDA Drug Label
5 mg twice daily) was effective (noninferior to warfarin) in reducing the risk of stroke (ischemic or hemorrhagic) and systemic embolism. Apixaban was superior to warfarin for the primary endpoint of reducing the risk of stroke and systemic embolism (Table 9 and Figure 4). Superiority to warfarin was primarily attributable to a reduction in hemorrhagic stroke and ischemic strokes with hemorrhagic conversion compared to warfarin.
The preferred oral anticoagulant in liver cancer and patient with history of a fib is apixaban, as it was shown to be superior to warfarin in reducing the risk of stroke and systemic embolism, with a lower rate of major bleeding 1.
- Key benefits of apixaban include:
- Reduced risk of stroke and systemic embolism
- Lower rate of major bleeding compared to warfarin
- Effective in patients with nonvalvular atrial fibrillation, including those with a history of stroke or systemic embolism However, it is essential to note that the label does not explicitly address liver cancer, and clinical decisions should be made with caution and consideration of individual patient factors.
From the Research
For patients with liver cancer and a history of atrial fibrillation, apixaban is the preferred oral anticoagulant due to its superior efficacy and safety profile compared to other direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) 2. The choice of anticoagulant should be individualized based on the patient's liver function, bleeding risk, drug interactions, and cancer stage.
- Key considerations include:
- Liver function: Patients with well-compensated liver function (Child-Pugh A) may be candidates for DOACs like apixaban, while those with moderate to severe liver dysfunction (Child-Pugh B or C) should avoid DOACs due to increased bleeding risk.
- Bleeding risk: The HAS-BLED score can be used to estimate bleeding risk, and apixaban has been shown to have a lower risk of major bleeding compared to rivaroxaban in patients with high bleeding risk 3.
- Drug interactions: Potential interactions between anticoagulants and cancer treatments, such as chemotherapy or radiation therapy, should be carefully considered.
- Cancer stage: The anticoagulation strategy may need to be adjusted based on the stage of liver cancer and the patient's overall health status. Regular monitoring of liver function, complete blood count, and coagulation parameters is essential to minimize the risk of bleeding and thromboembolic events.
- Monitoring should include:
- Liver function tests (e.g., ALT, AST, bilirubin)
- Complete blood count (e.g., platelet count, hemoglobin)
- Coagulation parameters (e.g., INR, aPTT) The anticoagulation strategy may need adjustment during cancer treatments like surgery, chemotherapy, or radiation therapy, requiring close coordination between oncology and cardiology teams 4.
- Coordination between teams is crucial to ensure that the anticoagulation strategy is optimized and that potential interactions between anticoagulants and cancer treatments are minimized.