Comparative Effectiveness and Safety among Apixaban, Dabigatran, Edoxaban, and Rivaroxaban for Atrial Fibrillation
ACP Journals: Annals of Internal Medicine: Published on
November, 2022
Current guidelines recommend using
direct oral anticoagulants (DOACs) over warfarin in patients with atrial
fibrillation (AF), but head-to-head trial data do not exist to guide the choice
of DOAC.
The aim
of the study is to do a large-scale comparison between all DOACs
(apixaban, dabigatran, edoxaban, and rivaroxaban) in routine clinical practice.
TAKE-HOME MESSAGE
In this international,
population-based, observational study involving 527,226 patients with a new
direct-acting oral anticoagulant (DOAC) prescription owing to recently
diagnosed atrial fibrillation (AF), apixaban was associated with a
substantially lower risk of GI bleeding compared with dabigatran, edoxaban, and
rivaroxaban.
The results remained consistent for
reduced-dose apixaban therapy versus reduced-dose rivaroxaban. The rates of
intracranial bleeding, systemic embolism, and mortality were similar for all
DOACs.
Conclusion:
These findings suggest that among
patients with AF, apixaban is associated with a substantially lower risk of GI
bleeding and similar rates of ischemic stroke or systemic embolism, ICH, and
all-cause mortality compared with dabigatran, edoxaban, and rivaroxaban.
This finding was consistent for patients aged 80 years or older and those with chronic kidney disease, who are often underrepresented in clinical trials.
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Background:
Current guidelines recommend using
direct oral anticoagulants (DOACs) over warfarin in patients with atrial
fibrillation (AF), but head-to-head trial data do not exist to guide the choice
of DOAC.
Objective:
To do a large-scale comparison
between all DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) in routine
clinical practice.
Design:
Multinational population-based
cohort study.
Setting:
Five standardized electronic health
care databases, which covered 221 million people in France, Germany, the United
Kingdom, and the United States.
Participants:
Patients who were newly diagnosed
with AF from 2010 through 2019 and received a new DOAC prescription.
Measurements:
Database-specific hazard ratios
(HRs) of ischemic stroke or systemic embolism, intracranial hemorrhage (ICH),
gastrointestinal bleeding (GIB), and all-cause mortality between DOACs were
estimated using a Cox regression model stratified by propensity score and
pooled using a random-effects model.
Results:
A total of 527 226 new DOAC
users met the inclusion criteria. Apixaban use was associated with lower risk
for GIB than use of dabigatran, edoxaban, or rivaroxaban. No substantial
differences were observed for other outcomes or DOAC–DOAC comparisons. The
results were consistent for patients aged 80 years or older. Consistent
associations between lower GIB risk and apixaban versus rivaroxaban were
observed among patients receiving the standard dose, those receiving a reduced
dose, and those with chronic kidney disease.
Conclusion:
Among patients with AF, apixaban
use was associated with lower risk for GIB and similar rates of ischemic stroke
or systemic embolism, ICH, and all-cause mortality compared with dabigatran,
edoxaban, and rivaroxaban. This finding was consistent for patients aged 80
years or older and those with chronic kidney disease, who are often
underrepresented in clinical trials.
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