Which DOAC is best for gastrointestinal haemorrhage in atrial fibrillation patients?

Use of apixaban appears to reduce the risk of gastrointestinal haemorrhage (GIH) compared with dabigatran, rivaroxaban, and vitamin K antagonist (VKA) in patients with nonvalvular atrial fibrillation, a recent study has shown. On the other hand, rivaroxaban use tends to increase GIH risk relative to dabigatran and VKA.

A team of investigators systematically searched the databases of Medline and Embase until April 2021. They identified eligible observational studies and extracted hazard ratios (HRs) with 95 percent confidence intervals (CIs).

Subgroup analyses were conducted based on doses of direct oral anticoagulants (DOACs), history of chronic kidney disease, stroke, prior exposure to VKA, age, gender, and geographic location of population samples. The investigators also performed Leave-One-Out and Low/Moderate Risk of Bias sensitivity analyses and used a random effects model.

Forty-six studies met the eligibility criteria. Treatment with apixaban resulted in a lower GIH risk compared with dabigatran (HR, 0.67, 95 percent CI, 0.56‒0.81; I², 53.28 percent), rivaroxaban (HR, 0.56, 95 percent CI, 0.44‒0.70; I², 79.17 percent), and VKA (HR, 0.68, 95 percent CI, 0.60‒0.78; I², 71.93 percent).

Conversely, treatment with rivaroxaban contributed to a higher GIH risk relative to dabigatran (HR, 1.19, 95 percent CI, 1.02‒1.40; I², 72.96 percent) and VKA (HR, 1.16, 95 percent CI, 1.05‒1.27; I², 81.95 percent). In addition, dabigatran correlated with a similar GIH risk when compared with VKA (HR, 1.11, 95 percent CI, 0.98‒1.26; I², 87.28 percent).