Cadth 2015 e5 ad panel discussion af

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?

January 2013

April 2015

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

CCS AF Guidelines GRADE

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)

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

Committee make-up

INTERNIST

GASTROENTEROLOGIST

ER PHYSICIAN

HEMATOPATHOLOGIST

HEMATOLOGIST

NEPHROLOGIST

NEUROLOGIST

CARDIOLOGIST

FAMILY PHYSICIAN

• 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.