Boehringer Ingelheim Presents New Praxbind® (idarucizumab) Analyses on Reintroduction of Antithrombotic Therapy after Reversal of Dabigatran

● RE-VERSE AD™ interim analysis suggests reintroduction of alternate antithrombotic therapy possible at any time after idarucizumab administration
● Findings from an in vitro study suggest idarucizumab does not impact the effect of other commercially available blood thinners
● In vitro study results also suggest that the reversal effect of idarucizumab on dabigatran is not affected by the presence of coagulation factor concentrates

RIDGEFIELD, Conn., November 9, 2015 – Today, Boehringer Ingelheim announced results from two new analyses evaluating idarucizumab, recently approved under the Accelerated Approval pathway and marketed in the U.S. as Praxbind®, a specific reversal agent for Pradaxa® (dabigatran etexilate mesylate), that were presented at the American Heart Association (AHA) Scientific Sessions 2015 in Orlando. The analysis examined reinitiation of antithrombotic therapy after administration of idarucizumab. The reinitiation of antithrombotic therapy in patients with nonvalvular atrial fibrillation (NVAF) is important in order to address the underlying risk of stroke.

An interim analysis of data from the ongoing phase III RE-VERSE AD™ trial showed reinitiation of alternative antithrombotic therapy was possible any time after idarucizumab use. Reinitiation of alternative antithrombotic therapy (e.g. heparin) after treatment with idarucizumab ranged from 0.2 days to 77.2 days in patients who presented with uncontrolled or life-threatening bleeding and 0 days to 40.8 days in patients requiring emergency surgery or an urgent procedure. Reinitiation of PRADAXA after treatment with idarucizumab ranged from 1.3 days to 90.6 days in patients with uncontrolled or life-threatening bleeding, and 1 day to 63.31 days in patients requiring emergency surgery or an urgent procedure.

“Reinitiation of antithrombotic therapy as soon as medically appropriate should be considered to reduce the underlying stroke risk for patients with nonvalvular atrial fibrillation (NVAF),” said Charles Pollack, MD, Associate Provost and Professor of Emergency Medicine, Thomas Jefferson University in Philadelphia, and lead investigator of RE-VERSE AD. “The findings from this interim analysis from the phase III RE-VERSE AD study may provide physicians added insight into the reinitiation of antithrombotic therapy after dabigatran reversal in the rare emergency situations where administration of idarucizumab is deemed necessary.”

A second presentation on idarucizumab included findings from an in vitro study investigating the efficacy of idarucizumab in the presence of coagulation factor concentrates [e.g., blood-clotting proteins recombinant Factor VIIa, 3- or 4-factor prothrombin complex concentrates (PCC), and activated PCC]. The results suggest that the use of idarucizumab did not inhibit the anticoagulation effects of other commercially available blood thinners (direct factor Xa inhibitors, heparins, or other direct thrombin inhibitors). The study also showed that the reversal effect of idarucizumab on dabigatran was not affected by the presence of coagulation factor concentrates. This result is important as these agents are frequently used in the management of patients presenting with acute hemorrhages. 

“The data presented at AHA reinforce the clinical evidence on the use of idarucizumab in treating PRADAXA patients in emergency or urgent settings where reversal of anticoagulation is needed,” said Sabine Luik, MD, senior vice president, Medicine & Regulatory Affairs, Boehringer Ingelheim. “The data presented today support that, although idarucizumab will be rarely used in clinical practice, a specific reversal agent may provide an important therapeutic option for physicians and patients.”

About RE-VERSE AD™

RE-VERSE AD is a phase III global study that includes patients taking PRADAXA who have uncontrolled bleeding or require emergency procedures. The interim analysis from RE-VERSE AD included data from 90 patients with either uncontrolled or life-threatening bleeding complications, e.g. intracranial hemorrhage or severe trauma after a car accident (n= 51), or patients requiring emergency surgery or an urgent procedure, e.g. surgery for an open fracture after a fall (n=39). The study met its primary endpoint, achieving 100 percent maximum reversal as the median value within four hours of administration across all patients. Reversal was evident immediately after administration of the first vial of idarucizumab and was complete in all but 1 patient. In this interim analysis there were 18 deaths. Mortality could be attributed to a complication of the underlying reason for admission or associated with comorbidities. Thrombotic events occurred in five patients, none of whom was receiving antithrombotic therapy at the time of the event.

About Praxbind® (idarucizumab)

IMPORTANT SAFETY INFORMATION

WARNINGS AND PRECAUTIONS
Thromboembolic Risk

  • Dabigatran-treated patients have underlying diseases predisposing them to thromboembolic events.  Reversing dabigatran therapy exposes patients to the thrombotic risk of their underlying disease.  To reduce this risk, resumption of anticoagulant therapy should be considered as soon as medically appropriate.

Re-elevation of Coagulation Parameters

  • Elevated coagulation parameters (e.g., activated partial thromboplastin time or ecarin clotting time) have been observed in a limited number of PRAXBIND-treated patients.  If reappearance of clinically relevant bleeding together with elevated coagulation parameters is observed or if patients requiring a second emergency surgery/urgent procedure have elevated coagulation parameters, an additional full dose may be considered.

Hypersensitivity Reactions

  • There is insufficient clinical experience evaluating risk of hypersensitivity to idarucizumab, but a possible relationship could not be excluded.  Risk of hypersensitivity (e.g., anaphylactoid reaction) to idarucizumab or excipients needs to be weighed cautiously against the potential benefit.  If serious allergic reaction occurs, immediately discontinue PRAXBIND and institute appropriate treatment.

Risk in Patients with Hereditary Fructose Intolerance

  • PRAXBIND contains 4 g sorbitol as an excipient.  When prescribing PRAXBIND in patients with hereditary fructose intolerance consider the total daily amount of sorbitol/fructose consumption from all sources as serious adverse reactions (e.g. hypoglycemia, hypophosphatemia, metabolic acidosis, increase in uric acid, acute liver failure and death) may occur. 

ADVERSE REACTIONS

  • The most frequently reported adverse reaction in ≥5% of idarucizumab-treated healthy volunteers was headache (12/224).   The most frequently reported adverse reactions in ≥5% of patients were hypokalemia (9/123), delirium (9/123), constipation (8/123), pyrexia (7/123) and pneumonia (7/123). 
  • As with all proteins there is a potential for immunogenicity with idarucizumab.  In treated patients, treatment-emergent antibodies with low titers were observed (9/224).

USE IN SPECIFIC POPULATIONS

Pregnancy and Nursing Mothers

  • PRAXBIND should be given to a pregnant or nursing woman only if clearly needed.

Please see full Prescribing Information.

INDICATIONS AND USAGE
PRAXBIND is indicated in patients treated with Pradaxa® when reversal of the anticoagulant effects of dabigatran is needed:

  • For emergency surgery/urgent procedures
  • In life‐threatening or uncontrolled bleeding

This indication is approved under accelerated approval based on a reduction in unbound dabigatran and normalization of coagulation parameters in healthy volunteers.  Continued approval for this indication may be contingent upon the results of an ongoing cohort case series study.

About Pradaxa® (dabigatran etexilate mesylate)

Indications and Usage
Pradaxa®(dabigatran etexilate mesylate) capsules is indicated:

  • to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation;
  • for the treatment of deep venous thrombosis and pulmonary embolism in patients who have been treated with a parenteral anticoagulant for 5-10 days;
  • to reduce the risk of recurrence of deep venous thrombosis and pulmonary embolism in patients who have been previously treated

IMPORTANT SAFETY INFORMATION ABOUT PRADAXA

WARNING: (A) PREMATURE DISCONTINUATION OF PRADAXA INCREASES THE RISK OF THROMBOTIC EVENTS, (B) SPINAL/EPIDURAL HEMATOMA

(A) PREMATURE DISCONTINUATION OF PRADAXA INCREASES THE RISK OF THROMBOTIC EVENTS
Premature discontinuation of any oral anticoagulant, including PRADAXA, increases the risk of thrombotic events. If anticoagulation with PRADAXA is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant  
(B) SPINAL/EPIDURAL HEMATOMA
Epidural or spinal hematomas may occur in patients treated with PRADAXA who are receiving neuraxial anesthesia or undergoing spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients for spinal procedures. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include:

  • use of indwelling epidural catheters
  • concomitant use of other drugs that affect hemostasis, such as non-steroidal anti‑inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants
  • a history of traumatic or repeated epidural or spinal punctures
  • a history of spinal deformity or spinal surgery
  • optimal timing between the administration of PRADAXA and neuraxial procedures is not known

Monitor patients frequently for signs and symptoms of neurological impairment. If neurological compromise is noted, urgent treatment is necessary.  Consider the benefits and risks before neuraxial intervention in patients who are or will be anticoagulated.

CONTRAINDICATIONS
PRADAXA is contraindicated in patients with:
-    active pathological bleeding;
-    known serious hypersensitivity reaction (e.g., anaphylactic reaction or anaphylactic shock) to
     PRADAXA;
-    mechanical prosthetic heart valve

WARNINGS & PRECAUTIONS
Increased Risk of Thrombotic Events after Premature Discontinuation
Premature discontinuation of any oral anticoagulant, including PRADAXA, in the absence of adequate alternative anticoagulation increases the risk of thrombotic events.  If PRADAXA is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant and restart PRADAXA as soon as medically appropriate.

Risk of Bleeding

  • PRADAXA increases the risk of bleeding and can cause significant and, sometimes, fatal bleeding. Promptly evaluate any signs or symptoms of blood loss (e.g., a drop in hemoglobin and/or hematocrit or hypotension). Discontinue PRADAXA in patients with active pathological bleeding.
  • Risk factors for bleeding include concomitant use of medications that increase the risk of bleeding (e.g., anti-platelet agents, heparin, fibrinolytic therapy, and chronic use of NSAIDs). PRADAXA’s anticoagulant activity and half-life are increased in patients with renal impairment.
  • Reversal of Anticoagulant Effect:  A specific reversal agent (idarucizumab) for dabigatran is available when reversal of the anticoagulant effect of dabigatran is needed:
    • For emergency surgery/urgent procedures
    • In life-threatening or uncontrolled bleeding 

Hemodialysis can remove dabigatran; however clinical experience for hemodialysis as a treatment for bleeding is limited.  Activated prothrombin complex concentrates, recombinant Factor VIIa, or concentrates of factors II, IX or X may be considered but their use has not been evaluated.  Protamine sulfate and vitamin K are not expected to affect dabigatran anticoagulant activity.  Consider administration of platelet concentrates where thrombocytopenia is present or long-acting antiplatelet drugs have been used.

Thromboembolic and Bleeding Events in Patients with Prosthetic Heart Valves
The use of PRADAXA is contraindicated in patients with mechanical prosthetic valves due to a higher risk for thromboembolic events, especially in the post-operative period, and an excess of major bleeding for PRADAXA vs. warfarin. Use of PRADAXA for the prophylaxis of thromboembolic events in patients with AFib in the setting of other forms of valvular heart disease, including bioprosthetic heart valve, has not been studied and is not recommended.

Effect of P-gp Inducers & Inhibitors on Dabigatran Exposure
Concomitant use of PRADAXA with P-gp inducers (e.g., rifampin) reduces exposure to dabigatran and should generally be avoided.  P-gp inhibition and impaired renal function are major independent factors in increased exposure to dabigatran.  Concomitant use of P-gp inhibitors in patients with renal impairment is expected to increase exposure of dabigatran compared to either factor alone.
Reduction of Risk of Stroke/Systemic Embolism in NVAF

  • For patients with moderate renal impairment (CrCl 30-50 mL/min), reduce the dose of PRADAXA to 75 mg twice daily when dronedarone or systemic ketoconazole is coadministered with PRADAXA.
  • For patients with severe renal impairment (CrCl 15-30 mL/min), avoid concomitant use of PRADAXA and P-gp inhibitors.

Treatment and Reduction in the Risk of Recurrence of DVT/PE

  • For patients with CrCl <50 mL/min, avoid use of PRADAXA and concomitant P-gp inhibitors

ADVERSE REACTIONS
The most serious adverse reactions reported with PRADAXA were related to bleeding.
NVAF

  • Most frequent adverse reactions leading to discontinuation of PRADAXA were bleeding & gastrointestinal (GI) events
  • PRADAXA 150 mg resulted in higher rates of major and any GI bleeds compared to warfarin.
  • In patients ≥75 years of age, the risk of major bleeding may be greater with PRADAXA vs warfarin.
  • Patients on PRADAXA 150 mg had an increased incidence of GI adverse reactions.  These were commonly dyspepsia (including abdominal pain upper, abdominal pain, abdominal discomfort, and epigastric discomfort) and gastritis-like symptoms (including GERD, esophagitis, erosive gastritis, gastric hemorrhage, hemorrhagic gastritis, hemorrhagic erosive gastritis, and GI ulcer).

DVT/PE

  • Rates of any GI bleeds were higher in patients receiving PRADAXA 150 mg vs warfarin and placebo
  • In the active-controlled studies, there was a higher rate of clinical myocardial infarction (MI) in PRADAXA patients [20 (0.66/100) patient-years)] vs warfarin [5 (0.17/100 patient-years)].  In the placebo-controlled study, there was similar rate of non-fatal and fatal clinical MI in PRADAXA patients [1 (0.32/100 patient-years)] vs placebo [1 (0.34/100 patient-years)].
  • GI adverse reactions were similar in patients receiving PRADAXA 150 mg vs warfarin.  They were commonly dyspepsia (including abdominal pain upper, abdominal pain, abdominal discomfort, and epigastric discomfort) and gastritis-like symptoms (including gastritis, GERD, esophagitis, erosive gastritis and gastric hemorrhage).

Drug hypersensitivity reactions were reported in ≤ 0.1% of patients receiving PRADAXA.

Other Measures Evaluated
In NVAF patients, a higher rate of clinical MI was reported in patients who received PRADAXA (0.7/100 patient-years for 150 mg dose) than in those who received warfarin (0.6).

Please see full Prescribing Information, including boxed WARNING and Medication Guide.

About Boehringer Ingelheim
Boehringer Ingelheim Pharmaceuticals, Inc., based in Ridgefield, CT, is the largest U.S. subsidiary of Boehringer Ingelheim Corporation.

Boehringer Ingelheim is one of the world’s 20 leading pharmaceutical companies. Headquartered in Ingelheim, Germany, the company operates globally with 146 affiliates and more than 47,000 employees. Since its founding in 1885, the family-owned company has been committed to researching, developing, manufacturing and marketing novel treatments for human and veterinary medicine.

Boehringer Ingelheim is committed to improving lives and providing valuable services and support to patients and families. Our employees create and engage in programs that strengthen our communities. To learn more about how we make more health for more people, visit our Corporate Social Responsibility Report.

In 2014, Boehringer Ingelheim achieved net sales of about $16.96 billion dollars (13.3 billion euros). R&D expenditure corresponds to 19.9 percent of its net sales.

For more information please visit www.us.boehringer-ingelheim.com, or follow us on Twitter @BoehringerUS.  

Boehringer Ingelheim Pharmaceuticals, Inc. either owns or uses the trademarks Pradaxa®, Praxbind® and RE-VERSE AD™ under license.

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