Use of apixaban was associated with a lower risk of gastrointestinal bleed and similar rates of ischaemic stroke or systemic embolism, intracranial haemorrhage and all-cause mortality compared to other direct oral anticoagulants in patients with atrial fibrillation (AF), research published in the Annals of Internal Medicine suggests.
This is the conclusion of a multinational population-based cohort study authored by Walls Lau (University College London School of Pharmacy, London, UK) and colleagues, comparing the use of the direct oral anticoagulants apixaban, dabigatran, edoxaban, and rivaroxaban in routine clinical practice, based upon data from five standardised electronic healthcare databases, covering 221 million people in France, Germany, UK and USA.
Included in the study were 527,226 patients newly diagnosed with AF, from 2010 through to 2019, receiving a new direct oral anticoagulant prescription.
Database-specific hazard ratios (HRs) of ischaemic stroke or systemic embolism, intracranial haemorrhage, gastrointestinal bleeding, and all-cause mortality between direct oral anticoagulants were estimated using a Cox regression model stratified by propensity score and pooled using a random-effects model.
Of the total study population, 281,320 received apixaban, 61,008 dabigatran, 12,722 edoxaban, and 172,176 rivaroxaban. Lau and colleagues report that apixaban use was associated with lower risk for gastrointestinal bleeding than use of dabigatran (HR 0.81, 95% confidence interval [CI] 0.70‒0.94), edoxaban (HR 0.77, CI, 0.66‒0.91), or rivaroxaban (HR 0.72, CI 0.66‒0.79). No substantial differences were observed for other outcomes or anticoagulant to anticoagulant comparisons.
The results were consistent for patients aged 80 years or older, the study team reports, and consistent associations between lower gastrointestinal bleeding risk and apixaban versus rivaroxaban were observed among patients receiving the standard dose (HR 0.72, CI 0.64‒0.82), those receiving a reduced dose (HR 0.68, CI 0.61‒0.77), and those with chronic kidney disease (HR 0.68, CI 0.59‒0.77).
“Direct oral anticoagulants have been prescribed with increasing frequency worldwide in recent years, but evidence comparing them directly has been limited,” comments Lau. “Our results indicate that apixaban may be preferable to other blood thinners because of the lower rate of gastrointestinal bleeding and similar rates of stroke, a finding that we hope will be supported by randomised controlled trials.
“As with all medications, potential risks and benefits can differ between people, so considering the full spectrum of outcomes and side-effects will still be necessary for each individual patient.”