Apixaban bests rivaroxaban, on par with dabigatran in reducing stroke, bleeding risks

Use of apixaban for nonvalvular atrial fibrillation (NVAF) appears better than rivaroxaban in reducing the risks of stroke and bleeding but is associated with similar risks relative to dabigatran, a study has shown.

The investigators performed multicentre matched cohort studies with secondary meta-analyses to examine the safety and effectiveness of dabigatran, rivaroxaban, and apixaban across nine administrative healthcare databases. They included adults with NVAF initiating direct oral anticoagulants (DOACs) and divided them into three cohort to compare DOACs pairwise.

The primary endpoint was the pooled hazard ratio (pHR) of ischaemic stroke or systemic thromboembolism; secondary ones were pHRs of major bleeding and a composite of stroke, major bleeding, or all-cause mortality. Proportional hazard Cox regression models were used, and pooled estimates were obtained through random effect meta-analyses.

Overall, there were 73,414 new users of dabigatran, 92,881 of rivaroxaban, and 61,284 of apixaban. For rivaroxaban vs dabigatran, the pHRs were 1.11 (95 percent confidence interval [CI], 0.93–1.32) for ischaemic stroke or systemic embolism, 1.26 (95 percent CI, 1.09–1.46) for major bleeding, and 1.17 (95 percent CI, 1.05–1.30) for the composite endpoint.

The pHRs comparing apixaban to dabigatran were 0.91 (95 percent CI, 0.74–1.12), 1.26 (95 percent CI, 1.09–1.46), and 1.17 (95 percent CI, 1.05–1.30) for ischaemic stroke or systemic embolism, major bleeding, and the composite endpoint, respectively. For apixaban vs rivaroxaban, the corresponding pHRs were as follows: 0.85 (95 percent CI, 0.74–0.99), 0.61 (95 percent CI, 0.53–0.70), and 0.83 (95 percent CI, 0.76–0.88).