Place of Factor XI Inhibitors in Stroke Prevention in Clinical Practice

In the final episode, “Place of Factor XI Inhibitors in Stroke Prevention in Clinical Practice,”Ashkan Shoamanesh, MD, FRCPC, FESO, James Siegler, MD, Greg Albers, MD, and Eva Mistry, MD explored the following:

1. Where do see Factor XIa targeting drugs fitting in secondary stroke prevention strategies?

Asundexian’s number needed to treat of about 50 at one year is markedly better than many prior stroke-prevention benchmarks (e.g., clopidogrel vs aspirin, early aspirin, DOACs in AF, device‑detected AF trials), making its incremental benefit particularly impressive given it is added on top of modern lipid, blood pressure, and antiplatelet therapy. Panelists expect this efficacy and safety profile to be “practice-changing,” given the large U.S. ischemic stroke burden (~800,000 cases/year) and the persistent long‑term risk of recurrence, even in patients treated months or years earlier. The results also heighten optimism for the parallel LIBREXIA-STROKE program with milvexian; if positive, it would likely elevate factor XIa inhibition to a Class I, Level A recommendation, with two large confirmatory trials. Until asundexian reaches the market, investigators see enrollment in LIBREXIA-STROKE as the only current pathway to offer patients factor XIa inhibition after non‑cardioembolic ischemic stroke.

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