Milvexian: evaluating the factor XIa inhibitor for the treatment of acute coronary syndrome

ABSTRACT

Introduction

Balancing the prevention of thrombosis with bleeding risk when combining anticoagulants and platelet antagonists remains a concern among clinicians, particularly in patients with acute coronary syndrome (ACS) who are treated with potent antiplatelet therapy. This may be because the available antiplatelet and anticoagulants are unable to uncouple physiological hemostasis and pathological thrombosis. Therefore, their use is associated with an unavoidable elevated risk of bleeding.

Areas covered

Evidence available from studies evaluating FXIa inhibitors and milvexian were collected from a selective literature search. In this review, the authors describe the potential role of FXI/XIa in experimental thrombosis, evidence for FXIa inhibition in the treatment of clinical thrombotic events and highlight the current evidence supporting the role of milvexian, a novel FXIa inhibitor, in patients with ACS.

Expert opinion

The ongoing LIBREXIA-ACS trial is the large-scale study currently investigating milvexian in patients with ACS. This study may support the proof of concept of differentiating physiological hemostasis and pathological thrombosis and achieving maximum antithrombotic efficacy with minimum bleeding risk when used on top of DAPT with potent P2Y₁₂ receptor blockers.

KEYWORDS:

• Acute coronary syndrome
• bleeding
• anticoagulants
• FXIa inhibitors
• milvexian

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Declaration of Interests

P A Gurbel has received consulting fees and/or honoraria from Bayer, Vectura/Otitopic, Janssen, Cleveland Clinic foundation, Wolters Kluwer Pharma, Web MD Medscape, Baron and Budd, Premier Health Care Resource, Baim Institute, and Medforce; institutional research grants from Accriva Diagnostics, AstraZeneca, Bayer, Cronos, Janssen Pharmaceuticals Inc., Haemonetics, Hikari Dx, Idorisa, Labcorp Drug Development, Novartis, Prolocor, Recor Medical, Vectura Limited, Zoll Medical Corporation; in addition, P A Gurbel has two patents, Detection of restenosis risk in patients issued and Assessment of cardiac health and thrombotic risk in a patient. P A Gurbel was an expert witness in a lawsuit associated with Plavix.

U S Tantry has received honoraria from Wolters Kluwer Pharma.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Article highlights

• The available direct oral anticoagulants (FXa and FIIa inhibitors) are unable to uncouple physiological hemostasis and pathological thrombosis. Therefore, their use is associated with an unavoidable elevated risk of bleeding.

• FXIa inhibition has been hypothesized to differentiate physiological hemostasis and pathological thrombosis and therefore associated with maximum antithrombotic efficacy with minimum bleeding risk when used on top of DAPT with potent P2Y₁₂ receptor blockers.

• Milvexian has a rapid onset with maximum exposure achieved at 2-4 hours, potent antithrombotic effect and a rapid offset with terminal half-life of 8-13 hours. Therefore, twice daily dosing has been studied in phase II trials and will be evaluated in the ongoing phase III trial in patients with ACS.

Additional information

Funding

This paper was not funded.