New anticoagulant asundexian prevents recurrent ischaemic stroke without increasing bleeding: PACIFIC-Stroke

New anticoagulant asundexian prevents recurrent ischaemic stroke without increasing bleeding risk according to PACIFIC-Stroke trial. Further asundexian inhibited factor XIa for reducing ischaemic stroke and transient ischaemic attack (TIA).The PACIFIC-Stroke trial failed to reach its primary endpoint but the revelation was following an exploratory analysis.

The late breaking research was presented in a Hot Line session at ESC Congress 2022.

Study author Dr. Ashkan Shoamanesh of the Population Health Research Institute, Hamilton, Canada said: "This was the first completed randomised trial comparing factor XIa inhibition versus placebo, both on top of antiplatelet therapy, for secondary prevention of non-cardioembolic ischaemic stroke. The results of PACIFIC-Stroke indicate that the potential of asundexian to prevent stroke in selected patients should be investigated further."

Ischaemic stroke patients are at an increased risk of having another stroke, and long-term antiplatelet therapy is recommended to reduce recurrence.2 It is estimated that more than 6% of patients with non-cardioembolic ischaemic stroke will have another stroke within a year despite guideline-recommended treatment.3 Dr. Shoamanesh said: "More effective preventive strategies are needed for secondary stroke prevention.

Dual pathway inhibition combining an anticoagulant with an antiplatelet agent is hypothetically appealing, but there have been concerns that currently available oral anticoagulants may raise the likelihood of bleeding. There is emerging evidence that factor XIa inhibitors, such as asundexian, may prevent thrombosis without increasing bleeding.4,5

The phase 2 PACIFIC-Stroke trial investigated the efficacy, safety and optimal dosage of asundexian for secondary stroke prevention following an acute non-cardioembolic ischaemic stroke. The trial was conducted at 196 sites in 23 countries. A total of 1,808 patients were randomised within 48 hours (mean interval 36 hours) of non-cardioembolic ischaemic stroke to once daily asundexian 10 mg, 20 mg, 50 mg, or placebo on top of usual antiplatelet therapy. The average age was 67 years and 34% were women.

Participants underwent brain magnetic resonance imaging (MRI) at study entry and after six months, with images independently analysed by two radiologists blinded to treatment allocation. Patients were followed up for six to 12 months.

The primary efficacy outcome was the dose-response effect on the composite of incident MRI-detected covert brain infarcts or recurrent symptomatic ischaemic stroke at six months. The primary safety outcome was major or clinically-relevant non-major bleeding at 12 months. Secondary exploratory outcomes included ischaemic stroke and the composite of ischaemic stroke and TIA.

There were 362 primary efficacy outcomes at six months, 87 (19.1%) in the placebo group, 86 (18.9%) in the asundexian 10 mg group, 99 (22%) in the 20 mg group and 90 (20.1%) in the 50 mg group. There was no dose-dependent reduction of the primary efficacy outcome with asundexian (t-statistic: -0.68, p=0.80) at six months.

During the total follow-up (median 10.6 months), 125 recurrent symptomatic ischaemic strokes or TIA occurred, 38 (8.3%) in the placebo group, 35 (7.7%) in the asundexian 10 mg group, 28 (6.2%) in the 20 mg group and 24 (5.4%) in the 50 mg group. In a secondary exploratory analysis, recurrent ischaemic stroke or TIA was reduced among patients assigned to asundexian 50 mg compared with placebo (hazard ratio [HR] 0.64, 90% confidence interval [CI] 0.41–0.98), with the largest reduction among those with extracranial or intracranial atherosclerotic plaque (HR 0.39, 90% CI 0.18–0.85).

The primary safety outcome was not significantly increased at 12 months with asundexian, occurring in 2.4% of patients assigned to placebo and 3.9% of those assigned to asundexian (HR 1.57, 90% CI 0.91-2.71).

Dr. Shoamanesh said: "The promising results from this phase 2 trial require validation in an adequately-powered phase 3 randomised trial before being applied to clinical care for secondary stroke prevention. These findings may form the foundation for a phase 3 study investigating asundexian in addition to antiplatelet therapy in patients with non-cardioembolic ischaemic stroke."

Reference:

1. Dawson J, Béjot Y, Christensen LM, et al. European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack. Eur Stroke J. 2022. doi:10.1177/23969873221100032.

2. Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369:11–19.

3. Hsu C, Hutt E, Bloomfield DM, et al. Factor XI inhibition to uncouple thrombosis from hemostasis: JACC review topic of the week. J Am Coll Cardiol. 2021;78:625–631.

4. Piccini JP, Caso V, Connolly SJ, et al. Safety of the oral factor XIa inhibitor asundexian compared with apixaban in patients with atrial fibrillation (PACIFIC-AF): a multicentre, randomised, double-blind, double-dummy, dose-finding phase 2 study. Lancet. 2022;399:1383–1390.