Right Chukwuneme: Daltaparin vs Apixaban – Efficacy or Safety Paradox?
Right Chukwuneme, Nurse Manager at Smyth Lodge-CareUK, President/Board Chairman at Legacy Healthcare Foundation, shared on LinkedIn:
”Daltaparin vs Apixaban – Efficacy or Safety Paradox?
The primary argument for dalteparin often rests on its historical status as a first point of call for clinicians.
However, recent evidence suggests that apixaban is at least as effective:
In the landmark CARAVAGGIO Trial (2017), apixaban was found to be non-inferior to dalteparin for the treatment of VTE in cancer patients.
Furthermore, Meta-analyses show no statistically significant difference in major bleeding between the two drugs.
While some data from a couple of researchers suggest dalteparin might have a lower risk of clinically relevant non-major bleeding (CRNMB), this must be weighed against the daily burden of injections and the financial burden it brings on the Healthcare System.
Clinical Gaps in the “Dalteparin First” Approach brings to bare the case for dalteparin which often relies on its perceived safety in specific high-risk groups, yet the data is often thin.
No Validated Superiority: Critically, no clinical trial has definitively proven that dalteparin is superior to apixaban across all cancer types. In many subgroups, such as patients under 65, apixaban may even be more effective.
Gastrointestinal (GI) Safety: Unlike other oral anticoagulants (like rivaroxaban or edoxaban), apixaban did not show a statistically significant increase in GI bleeding compared to dalteparin in the CARAVAGGIO study, even in patients with GI cancers.
The Paradox – The Ethical Case for Patient Choice
When clinical outcomes are comparable, the “tie-breaker” should be the patient’s quality of life and preference:
Treatment Burden: Dalteparin requires daily subcutaneous injections, which can cause bruising, pain, and significant psychological distress to patients while Apixaban is a twice-daily easy to swallow pill.
Quality of Life (QoL): Another like study named The ADAM VTE Trial (2018) specifically highlighted that patients on apixaban reported significantly higher satisfaction and lower treatment burden compared to those on dalteparin.
“Oral apixaban therapy was associated with very low rates of bleeding and significantly lower VTE recurrence with superior quality of life outcome measures compared to parenteral dalteparin in the treatment of cancer associated VTE.
These data support the clinical utility of apixaban for the acute treatment of VTE in this patient population.” Robert D McBane et al, 2017.
Shared Decision-Making: Since the data suggests apixaban is a valid oral alternative for most patients, denying this choice without a specific medical contraindication (like severe malabsorption or drug-drug interactions) contradicts the principles of patient-centred care.
Insisting on dalteparin solely because “it came first” ignores the non-inferiority data and the substantial improvement in patient satisfaction offered by apixaban.”
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