Factor XI Inhibitors in Early Clinical Trials: A Meta-analysis

Abstract

Background Phase II randomized controlled trials (RCTs) on factor(F)XI inhibitors have shown promising results but they were burdened by low statistical power for clinical outcomes.

Methods We performed a systematic review and meta-analysis of RCT comparing FXI inhibitors versus other anticoagulants (enoxaparin or direct oral anticoagulants, DOACs) or versus placebo on top of antiplatelet therapy.

Results Eight RCTs testing FXI inhibitors (ISIS 416858, osocimab, abelacimab, milvexian, asundexian) and enrolling 9,216 patients were included. Compared with enoxaparin, FXI inhibitors were associated with reduced any-bleeding (risk ratio [RR]: 0.49, 95% confidence interval [CI]: 0.31–0.77), no difference in major bleeding (RR: 0.96, 95% CI: 0.41–2.28), and reduced trial-defined efficacy endpoint (RR: 0.62, 95% CI: 0.49–0.79), the latter driven by the high-dose regimens. Compared with DOACs, FXI inhibitors were associated with a trend toward reduced any-bleeding (RR: 0.66, 95% CI: 0.31–1.38) and no difference in major bleeding (RR: 1.03, 95% CI: 0.22–4.78) or in trial-defined efficacy endpoint (RR: 1.23, 95% CI: 0.88–1.70). Compared with placebo, FXI inhibitors were associated with increased any-bleeding (RR: 1.25, 95% CI: 1.08–1.43) and a trend toward increased major bleeding (RR: 1.21, 95% CI: 0.75–1.93), both driven by high-dose regimens, with no difference in trial-defined efficacy endpoint (RR: 1.02, 95% CI: 0.92–1.13).

Conclusion Results of this meta-analysis on FXI inhibitors suggest increased safety and efficacy compared with enoxaparin and modest increased safety compared with DOACs. The use of FXI inhibitors in adjunct to antiplatelet therapy versus placebo appears to be associated with a dose-dependent increase in bleeding without any difference in efficacy.

Study registration This study is registered in PROSPERO (CRD42022367706).

Keywords

FXI inhibitors - low-molecular-weight heparin - direct oral anticoagulant - placebo - bleeding

Data Availability Statement

The data underlying this article are available in the article and in its online [Supplementary Material] (available in the online version).

Authors' Contribution

M.G. conceived and designed the study. M.G. and R.L. independently assessed studies for possible inclusion and collected the data. M.G. and R.L. analyzed the data. M.G. supervised the analysis. M.G. and D.J.A. drafted the manuscript. All authors revised and approved the final version of the manuscript.

Publication History

Received: 24 December 2022

Accepted: 23 February 2023

Accepted Manuscript online:
25 February 2023

Article published online:
24 March 2023

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