Apixaban, Rivaroxaban, and Other DOACs in Nonvalvular Atrial Fibrillation

In a recent study published in BMJ Open, researchers compared the safety and efficacy of various direct oral anticoagulants (DOACs) for stroke prevention in patients with nonvalvular atrial fibrillation. According to the study’s lead author, Ashley Jaksa, apixaban was as effective as rivaroxaban for reducing the incidence of stroke and was safer for major bleeding episodes.

This study enrolled 5655 patients aged 18 years or more with nonvalvular atrial fibrillation who received at least one DOAC between July 2014 and December 2020. The DOACs included were apixaban, rivaroxaban, edoxaban, and dabigatran.

The primary end point of the study was ischemic or hemorrhagic stroke, and secondary endpoints were all-cause mortality, myocardial infarction (MI), transient ischemic attacks, major bleeding events, and a composite of angina, MI, and stroke (AMS).

Apixaban Slightly Advantaged Compared With Rivaroxaban

Among all patients, 2801 received apixaban, 2221 received rivaroxaban, 398 received edoxaban, and 261 received dabigatran. The rates of stroke per 1000 person-years were 12.47 in the apixaban group and 13.48 in the rivaroxaban group.

According to the authors, patients starting apixaban showed rates similar to rivaroxaban for:

  • Stroke (hazard ratio [HR], 0.93; 95% CI, 0.64-1.34)
  • All-cause mortality (HR, 1.03; 95% CI, 0.87-1.22)
  • MI (HR, 0.95; 95% CI, 0.54-1.68)
  • TIA (HR, 1.03; 95% CI, 0.61-1.72)
  • AMS (HR, 0.96; 95% CI, 0.72-1.27)

The researchers did note that patients starting apixaban had lower rates of major bleeding events (HR, 0.60; 95% CI, 0.47-0.75) compared with rivaroxaban.

In secondary analyses, the rate of stroke was similar between 2276 apixaban patients and 2276 matched patients on other DOACs (HR, 0.90; 95% CI, 0.64-1.27). Likewise, the rate of stroke was comparable between 1985 rivaroxaban patients and 1985 matched patients on other DOACs (HR, 0.96; 95% C I, 0.67-1.36).

In summary, the authors wrote that “this head-to-head comparison supports conclusions drawn from indirect comparisons of DOAC trials against warfarin and demonstrates the potential for real-world evidence to fill evidence gaps and reduce uncertainty in both health technology assessment decision-making and clinical guideline development.

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