Switching From DAPT to Dual Pathway Inhibition With Low-dose Rivaroxaban in Adjunct to Aspirin in Patients With Coronary Artery Disease (SWAP-AC)

University of Florida

Status and phase: Completed; Phase 4

Conditions: Coronary Artery Disease

Treatments: Drug: aspirin; Drug: ticagrelor; Drug: Clopidogrel; Drug: Prasugrel; Drug: rivaroxaban

Study type: Interventional

Funder types: Other; Industry

Identifiers

NCT04006288

IIS-RIVA02

Details and patient eligibility

About

Recent studies indicate that anti-factor-Xa inhibition with low-dose rivaroxaban may have a role in the reduction of ischemic recurrences in patients with atherosclerotic disease manifestations. The objectives of this investigation are to assess the feasibility of switching from a DAPT to DPI regimen and to compare the pharmacodynamic profiles of these treatment regimens. This will be a prospective study conducted in cohorts of patients with CAD on treatment per standard of care with DAPT. Patients will be randomized to either maintain DAPT or to DPI. DPI consists in treatment with aspirin (81mg/qd) plus rivaroxaban (2.5mg/bid).

Full description

Recent studies indicate that anti-factor-Xa inhibition with low-dose rivaroxaban may have a role in the reduction of ischemic recurrences in patients with atherosclerotic disease manifestations. In the COMPASS trial, patients with stable coronary or peripheral artery disease and no indication for oral anticoagulation or dual antiplatelet therapy (DAPT) were randomized to rivaroxaban 2.5 mg bid in combination with aspirin, rivaroxaban 5 mg bid monotherapy or aspirin monotherapy. The study showed a significant 24% relative reduction in ischemic outcomes with rivaroxaban 2.5 mg bid plus aspirin combination strategy compared with aspirin alone. These observations have raised practical considerations on how to implement the results of the COMPASS trial in clinical practice particularly for patients who are completing a minimum duration of DAPT and contemplating between continuing with a DAPT regimen versus switching to a dual pathway inhibition (DPI) regimen with aspirin plus rivaroxaban. Therefore, the objectives of this investigation are to assess the feasibility of switching from a DAPT to DPI regimen and to compare the pharmacodynamic profiles of these treatment regimens. This will be a prospective study conducted in cohorts of patients with CAD on treatment per standard of care with DAPT. Patients will be randomized to either maintain DAPT or to DPI. DPI consists in treatment with aspirin (81mg/qd) plus rivaroxaban (2.5mg/bid).

Enrollment: 90 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Willing and able to provide written informed consent

• Above 18 years of age

• Have known CAD and have completed their required duration of standard of care DAPT (aspirin in combination with either clopidogrel, prasugrel, or ticagrelor) and still be on treatment:

  • ≥ 6 months after an elective PCI
  • ≥ 12 months after experiencing an ACS (irrespective of revascularization at the time of ACS; thus patients treated by PCI, CABG, or medically managed can be considered)

Exclusion criteria

• Deemed to be at high risk of bleeding, active bleeding or history of major bleeding Stroke within 1 month or any history of hemorrhagic or lacunar stroke
• Estimated glomerular filtration rate <15 mL/min by MDRD equation
• Need for dual antiplatelet therapy, other non-aspirin antiplatelet therapy, or oral anticoagulant therapy
• Known non-cardiovascular disease that is associated with poor prognosis (e.g., metastatic cancer) or that increases the risk of an adverse reaction to study interventions.
• History of hypersensitivity or known contraindication for rivaroxaban.
• Systemic treatment with strong inhibitors of both CYP 3A4 and p-glycoprotein (e.g., systemic azole antimycotics, such as ketoconazole, and human immunodeficiency virus [HIV]-protease inhibitors, such as ritonavir), or strong inducers of CYP 3A4, i.e.

rifampicin, rifabutin, phenobarbital, phenytoin, and carbamazepine

• Any known hepatic disease associated with coagulopathy
• Subjects who are pregnant, breastfeeding, or are of childbearing potential, and sexually active and not practicing an effective method of birth control (e.g. surgically sterile, prescription oral contraceptives, contraceptive injections, intrauterine device, double barrier method, contraceptive patch, male partner sterilization)
• Concomitant participation in another study with investigational drug
• Known contraindication to any study related procedures
• Hemoglobin ≤9 mg/dL
• Platelet count <80x106/mL

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

---

90 participants in 6 patient groups

Aspirin and clopidogrel

Active Comparator group

Description:

aspirin 81 mg/qd plus clopidogrel 75mg/qd for 30 days

Treatment:

Drug: aspirin

Drug: Clopidogrel

Aspirin and rivaroxaban from aspirin and clopidogrel

Experimental group

Description:

aspirin 81mg/qd plus rivaroxaban 2.5mg/bid for 30 days

Treatment:

Drug: rivaroxaban

Drug: aspirin

Aspirin and prasugrel

Active Comparator group

Description:

aspirin 81 mg/qd plus prasugrel 10mg/qd for 30 days

Treatment:

Drug: Prasugrel

Drug: aspirin

Aspirin and rivaroxaban from aspirin and prasugrel

Experimental group

Description:

aspirin 81mg/qd plus rivaroxaban 2.5mg/bid for 30 days

Treatment:

Drug: rivaroxaban

Drug: aspirin

Aspirin and ticagrelor

Active Comparator group

Description:

aspirin 81 mg/qd plus ticagrelor 60mg/bid for 30 days

Treatment:

Drug: aspirin

Drug: ticagrelor

Aspirin and rivaroxaban from aspirin and ticagrelor

Experimental group

Description:

aspirin 81mg/qd plus rivaroxaban 2.5mg/bid for 30 days

Treatment:

Drug: rivaroxaban

Drug: aspirin