AVAJAK: Apixaban/Rivaroxaban Versus Aspirin for Primary Prevention of Thrombo-embolic Complications in JAK2V617F-positive Myeloproliferative Neoplasms

Regional University Hospital Center (CHRU)

Status and phase

Enrolling

Phase 3

Conditions

Polycythemia Vera

High-risk Patients

JAK2 V617F

Essential Thrombocythemia

Prefibrotic/Early Primary Myelofibrosis

Treatments

Drug: Low-dose aspirin

Drug: Direct Oral Anticoagulants

Study type

Interventional

Funder types

Other

Identifiers

NCT05198960

29BRC20.0263 (AVAJAK)

Details and patient eligibility

About

Philadelphia-negative myeloproliferative neoplasms (MPN) are frequent and chronic myeloid malignancies including Polycythemia Vera (PV), essential thrombocythemia (ET), Primary Myelofibrosis (PMF) and Prefibrotic myelofibrosis (PreMF). These MPNs are caused by the acquisition of mutations affecting activation/proliferation pathways in hematopoietic stem cells. The principal mutations are JAK2V617F, calreticulin (CALR exon 9) and MPL W515. ET or MFP/PreMF patients who do not carry one of these three mutations are declared as triple-negative (3NEG) cases even if they are real MPN cases.

These diseases are at high risk of thrombo-embolic complications and with high morbidity/mortality. This risk varies from 4 to 30% depending on MPN subtype and mutational status.

In terms of therapy, all patients with MPNs should also take daily low-dose aspirin (LDA) as first antithrombotic drug, which is particularly efficient to reduce arterial but not venous events.

Despite the association of a cytoreductive drug and LDA, thromboses still occur in 5-8% patients/year.

All these situations have been explored in biological or clinical assays. All of them could increase the bleeding risk. We should look at different ways to reduce the thrombotic incidence: Direct Oral Anticoagulants (DOAC)? In the general population, in medical or surgical contexts, DOACs have demonstrated their efficiency to prevent or cure most of the venous or arterial thrombotic events.

At the present time, DOAC can be used in cancer populations according to International Society on Thrombosis and Haemostasis (ISTH) recommendations, except in patients with cancer at high bleeding risk (gastro-intestinal or genito-urinary cancers). Unfortunately, in trials evaluating DOAC in cancer patients, most patients have solid rather than hematologic cancers (generally less than 10% of the patients, mostly lymphoma or myeloma).

In cancer patients, DOAC are also highly efficient to reduce the incidence of thrombosis (-30 to 60%), but patients are exposed to a higher hemorrhagic risk, especially in digestive cancer patients.

In the cancer population, pathophysiology of both thrombotic and hemorrhagic events may be quite different between solid cancers and MPN. If MPN patients are also considered to be cancer patients in many countries, the pathophysiology of thrombosis is quite specific (hyperviscosity, platelet abnormalities, clonality, specific cytokines...) and they are exposed to a lower risk of digestive hemorrhages. It is thus difficult to extend findings from the "general cancer population" to MPN patients.

Unfortunately, only scarce, retrospective data regarding the use of DOAC in MPNs are available data.

We were the first to publish a "real-life" study about the use, the impact, and the risks in this population. In this local retrospective study, 25 patients with MPN were treated with DOAC for a median time of 2.1 years. We observed only one thrombosis (4%) and three major hemorrhages (12%, after trauma or unprepared surgery). Furthermore, we have compared the benefit/risk balance compared to patients treated with LDA without difference.

With the increasing evidences of efficacy and tolerance of DOAC in large cohorts of patients including cancer patients, with their proven efficacy on prevention of both arterial and venous thrombotic events and because of the absence of prospective trial using these drugs in MPN patients, we propose to study their potential benefit as primary thrombotic prevention in MPN.

Enrollment

1,308 estimated patients

Sex

All

Ages

18+ years old

Volunteers

No Healthy Volunteers

Inclusion criteria

Patients with diagnosis of PV or ET or PreMF according to WHO or BSCH criteria (bone marrow biopsy not compulsory).
Patients with JAK2V617F mutation (threshold allele burden > 1%).
Patients considered as "high-risk" patients:
1. based on age (> 60-year-old)
2. based on thrombotic history (compatible with antithrombotic randomization) but aged ≥ 18-year-old.
Length of time from MPN diagnostic to inclusion will not exceed 12 months.

Exclusion criteria

Contra-indication to aspirin or DOAC due to allergic situation or recent history of major bleeding.
Formal indication of treatment with aspirin or DOAC (thus precluding randomization).
Inability to give informed consent.
Patients under curatorship/guardianship
Concomitant use of a strong inhibitor or inducer of CYP3A4 (like ruxolitinib).
Chronic liver disease or chronic hepatitis.
Renal insufficiency with creatinine <30 ml/mn on Cockcroft and Gault Formula
Patient considered at high-risk of bleeding: patients with current or recent major or clinical relevant non major bleeding gastrointestinal or cerebral bleedings
Planned pregnancy within 24 months
No appropriate contraception (estrogen contraception or no contraception) in women of childbearing age or breastfeeding woman
PS>2 or life expectancy <12 months.

Trial design

Primary purpose

Prevention

Allocation

Randomized

Interventional model

Parallel Assignment

Masking

None (Open label)

1,308 participants in 2 patient groups

Experimental group

Description:

Patients randomized to receive Direct Oral Anticoagulants, at the choice of the investigator Apixaban 2.5 mg both in day or Rivaroxaban 10 mg one per day, at the choice of the investigator

Treatment:

Drug: Direct Oral Anticoagulants

Control group

Active Comparator group

Description:

Patients randomized to receive Low-Dose Aspirin Aspirin 100 mg one per day

Treatment:

Drug: Low-dose aspirin