A 76-year-old woman with chronic lymphocytic leukemia on ibrutinibis noted to be in asymptomatic atrial fibrillation (AF) on a routine electrocardiogram performed in the hematology clinic for consideration of randomized controlled trial participation.
Background history includes:
Hypertension
Obesity (body mass index 35 kg/m2)
Hyperlipidemia
Nonobstructive coronary artery disease
Current medications include:
Aspirin 81 mg once daily
Hydrochlorothiazide 25 mg once daily
Atorvastatin 20 mg once daily
Omega-3 fatty acids 1 tablet twice daily
Laboratories performed at today's visit reveal:
White blood cell count 12,000/mL, hemoglobin 10 mg/dL, platelets 150,000/mcL
Estimated glomerular filtration rate 60ml/min/m2
Which one of the following is the best strategy for anticoagulation in this patient?
Show Answer
The correct answer is: C. Start apixaban 5 mg twice daily.
This patient has a CHA2DS2-VASc score of 4 and anticoagulation is recommended for stroke prophylaxis. Due to antiplatelet effects of ibrutinib, a review of indications for antiplatelet agents (nonsteroidal anti-inflammatory drugs, fish oil, vitamin E) is recommended, as is discontinuation of aspirin in patients at low or moderate cardiovascular risk. In this patient, stopping aspirin and fish oil would be recommended.
The choice of anticoagulant in patients with AF and ibrutinib therapy is based on the experience in randomized controlled trials, consideration of patient factors, and consideration of drug–drug interactions.
Vitamin K antagonists (VKAs) have been associated with unacceptable bleeding rates in combination with ibrutinib; therefore, use of warfarin in patients with AF would not be recommended.
Direct oral anticoagulants (DOACs) are the preferred anticoagulants over VKAs for patients with nonvalvular AF in the general population; reports in patients with AF and cancer indicate that the use of DOACs is safe and preferred over VKAs.In this case, apixaban is preferred over dabigatran due to drug–drug interactions. Dabigatran is a P-glycoprotein (P-gp) substrate, and avoidance of coadministration with ibrutinib is recommended due to P-gp–inhibiting properties of ibrutinib.
Low molecular weight heparin (LMWH) is often used for anticoagulation in patients with cancer; however, there are no trials assessing the long-term efficacy and safety of LMWH in patients with AF to prevent thromboembolism.
Drs. Jennifer R. Brown, MD, PhD; John Fanikos, RPH, MBA; Michael G. Fradley, MD served as peer reviewers for this patient case.
To visit the online course page for the Management of Afib in Oncology Patients: A Case Study in CCL Treatment, click here!
Byrd JC, Furman RR, Coutre SE, et al. Three-year follow-up of treatment-naïve and previously treated patients with CLL and SLL receiving single-agent ibrutinib. Blood 2015;125:2497-506.
January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019;74:104-32.
Shah S, Norby FL, Datta YH, et al. Comparative effectiveness of direct oral anticoagulants and warfarin in patients with cancer and atrial fibrillation. Blood Adv2018;2:200-9.
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