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Randomized Evaluation of Long-term anticoagulant therapY

Randomized Evaluation of Long-term anticoagulant therapY. Dabigatran Compared to Warfarin in 18,113 Patients with Atrial Fibrillation at Risk of Stroke Sponsored by Boehringer-Ingelheim. Atrial Fibrillation and Stroke. AF responsible for 1/6 of all strokes Warfarin reduces stroke in AF by 64%

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Randomized Evaluation of Long-term anticoagulant therapY

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  1. Randomized Evaluation of Long-term anticoagulant therapY Dabigatran Compared to Warfarin in 18,113 Patients with Atrial Fibrillation at Risk of Stroke Sponsored by Boehringer-Ingelheim

  2. Atrial Fibrillation and Stroke • AF responsible for 1/6 of all strokes • Warfarin reduces stroke in AF by 64% • significant increase in intracranial and other hemorrhage • Difficult to use • Only 50% of eligible patients receive warfarin • An alternative treatment is needed

  3. Dabigatran • Dabigatran Etexilate, a pro-drug, is rapidly converted to dabigatran • 6.5% bioavailability, 80% excreted by kidney • Half-life of 12-17 hours • Phase 2 data identified 110 mg BID and 150 mg BID as viable doses

  4. RE-LY: A Non-inferiority Trial Atrial fibrillation ≥1 Risk Factor Absence of contra-indications 951 centers in 44 countries R Blinded Event Adjudication. Open Blinded Dabigatran Etexilate 150 mg BID N=6000 Warfarin adjusted (INR 2.0-3.0) N=6000 Dabigatran Etexilate 110 mg BID N=6000

  5. Trial Execution • Performed December 2005-March 2009 • Median Follow up 2.0 years • Follow up 99.9% complete • Mean TTR = 64% (patients on warfarin)

  6. Baseline Characteristics

  7. Superiority Non-inferiority p-value p-value Dabigatran 110 vs. Warfarin <0.001 0.34 <0.001 <0.001 Dabigatran 150 vs. Warfarin Margin = 1.46 0.50 0.75 1.00 1.25 1.50 HR (95% CI) Stroke or Systemic Embolism Dabigatran better Warfarin better

  8. 10 Outcome: Superiority Analysis

  9. Ischemic/Unspecified Stroke 0.08 0.06 Cumulative Hazard Rates 0.04 Dabigatran110 Warfarin 0.02 Dabigatran150 0.0 0 0.5 1.0 1.5 2.0 2.5 Years of Follow-up

  10. Hemorrhagic Stroke 0.04 0.03 Cumulative Hazard Rates 0.02 Warfarin 0.01 Dabigatran110 Dabigatran150 0.0 0 0.5 1.0 1.5 2.0 2.5 Years of Follow-up

  11. Bleeding

  12. MI, Death and Net clinical Benefit Net Clinical Benefit includes vascular events, death and major bleed

  13. Dabigatran 150 mg vs. 110 mg *Net Clinical Benefit includes vascular events, death and major bleed

  14. 0.4 0.3 Dabigatran150 Stopping Rates Dabigatran110 0.2 Warfarin 0.1 0.0 0 0.5 1.0 1.5 2.0 2.5 Years of Follow-up Permanent Discontinuation

  15. ALT or AST >3x ULN 0.04 0.03 Warfarin Dabigatran110 Cumulative Risk 0.02 Dabigatran150 0.01 0.0 0 0.5 1.0 1.5 2.0 2.5 Years of Follow-up

  16. Common Adverse Events *Occurred more commonly on dabigatran p<0.001

  17. Conclusions • Dabigatran 150 mg significantly reduced stoke compared to warfarin with similar risk of major bleeding • Dabigatran 110 mg had a similar rate of stroke as warfarin with significantly reduced major bleeding • Both doses markedly reduced intra-cerebral, life-threatening and total bleeding • Dabigatran had no major toxicity, but did increase dyspepsia and GI bleeding

  18. Conclusions • Both Dabigatran doses offer advantages over warfarin • Dabigatran 150 is more effective and dabigatran 110 has a better safety profile • There is potential to tailor therapy to individual patient characteristics

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