Direct Comparison of Dabigatran, Rivaroxaban, and Apixaban for Effectiveness and Safety in Nonvalvular Atrial Fibrillation
Peter A Noseworthy et al. Chest. 2016 Dec.
Abstract
Background: The introduction of non-vitamin K antagonist oral anticoagulants (NOACs) has been a major advance for stroke prevention in atrial fibrillation (AF). Patients and clinicians now have a choice between different NOACs, but there is no direct comparative effectiveness evidence to guide decision-making. We aimed to compare the effectiveness and safety of dabigatran, rivaroxaban, and apixaban in clinical practice.
Methods: Using a large US administrative claims database, we created three one-to-one propensity-score-matched cohorts of patients with nonvalvular AF who were users of dabigatran, rivaroxaban, or apixaban between October 1, 2010 and February 28, 2015 (rivaroxaban vs dabigatran, n = 31,574; apixaban vs dabigatran, n = 13,084; and apixaban vs rivaroxaban, n = 13,130). The primary outcomes were stroke and systemic embolism (effectiveness) and major bleeding (safety) that occurred during treatment. Cox proportional hazards models were used to compare outcomes in propensity-score-matched cohorts.
Results: We found no differences between the three NOACs in the risk of stroke or systemic embolism (hazard ratio [HR], 1.00; 95% CI, 0.75-1.32 for rivaroxaban vs dabigatran; HR, 0.82; 95% CI, 0.51-1.31 for apixaban vs dabigatran; and HR, 1.05; 95% CI, 0.64-1.72 for apixaban vs rivaroxaban). Apixaban was associated with a lower risk of major bleeding (HR, 0.50; 95% CI, 0.36-0.70; P < .001 vs dabigatran and HR, 0.39; 95% CI, 0.28-0.54; P < .001 vs rivaroxaban). Rivaroxaban was associated with an increased risk of major bleeding (HR, 1.30; 95% CI, 1.10-1.53; P < .01) and intracranial bleeding (HR, 1.79; 95% CI, 1.12-2.86; P < .05) compared with dabigatran.
Conclusions: Dabigatran, rivaroxaban, and apixaban appear to have similar effectiveness, although apixaban may be associated with a lower bleeding risk and rivaroxaban may be associated with an elevated bleeding risk.
Keywords: atrial fibrillation; bleeding; non-vitamin K antagonist oral anticoagulants; stroke.
Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
PubMed Disclaimer
Similar articles
- Direct comparative effectiveness and safety between non-vitamin K antagonist oral anticoagulants for stroke prevention in nonvalvular atrial fibrillation: a systematic review and meta-analysis of observational studies. Li G, Lip GYH, Holbrook A, Chang Y, Larsen TB, Sun X, Tang J, Mbuagbaw L, Witt DM, Crowther M, Thabane L, Levine MAH. Li G, et al. Eur J Epidemiol. 2019 Feb;34(2):173-190. doi: 10.1007/s10654-018-0415-7. Epub 2018 Jun 8. Eur J Epidemiol. 2019. PMID: 29948370
- Effectiveness and Safety of Dabigatran, Rivaroxaban, and Apixaban Versus Warfarin in Nonvalvular Atrial Fibrillation. Yao X, Abraham NS, Sangaralingham LR, Bellolio MF, McBane RD, Shah ND, Noseworthy PA. Yao X, et al. J Am Heart Assoc. 2016 Jun 13;5(6):e003725. doi: 10.1161/JAHA.116.003725. J Am Heart Assoc. 2016. PMID: 27412905 Free PMC article.
- Comparative effectiveness and safety of apixaban, dabigatran, and rivaroxaban in patients with non-valvular atrial fibrillation. Andersson NW, Svanström H, Lund M, Pasternak B, Melbye M. Andersson NW, et al. Int J Cardiol. 2018 Oct 1;268:113-119. doi: 10.1016/j.ijcard.2018.03.047. Epub 2018 Jun 20. Int J Cardiol. 2018. PMID: 29934230
- Real-World Setting Comparison of Nonvitamin-K Antagonist Oral Anticoagulants Versus Vitamin-K Antagonists for Stroke Prevention in Atrial Fibrillation: A Systematic Review and Meta-Analysis. Ntaios G, Papavasileiou V, Makaritsis K, Vemmos K, Michel P, Lip GYH. Ntaios G, et al. Stroke. 2017 Sep;48(9):2494-2503. doi: 10.1161/STROKEAHA.117.017549. Epub 2017 Jul 17. Stroke. 2017. PMID: 28716982 Review.
- An indirect comparison of dabigatran, rivaroxaban and apixaban for atrial fibrillation. Mantha S, Ansell J. Mantha S, et al. Thromb Haemost. 2012 Sep;108(3):476-84. doi: 10.1160/TH12-02-0093. Epub 2012 Jun 28. Thromb Haemost. 2012. PMID: 22740145 Review.
Cited by
- The WATCHMAN Device Review: A New Era for Stroke Prophylaxis. Khan S, Naz H, Khan MSQ, Ullah A, Satti DI, Malik J, Mehmoodi A. Khan S, et al. J Community Hosp Intern Med Perspect. 2023 May 8;13(3):10-20. doi: 10.55729/2000-9666.1183. eCollection 2023. J Community Hosp Intern Med Perspect. 2023. PMID: 37877058 Free PMC article. Review.
- Proton pump inhibitors and gastroprotection in patients treated with antithrombotic drugs: A cardiologic point of view. Abrignani MG, Lombardo A, Braschi A, Renda N, Abrignani V. Abrignani MG, et al. World J Cardiol. 2023 Aug 26;15(8):375-394. doi: 10.4330/wjc.v15.i8.375. World J Cardiol. 2023. PMID: 37771340 Free PMC article. Review.
- Atrial Fibrillation:: A Common Cause of Stroke. Tai W. Tai W. Dela J Public Health. 2023 Aug 31;9(3):12-15. doi: 10.32481/djph.2023.08.004. eCollection 2023 Aug. Dela J Public Health. 2023. PMID: 37701476 Free PMC article.
- Effectiveness of Transcatheter Closure of Patent Foramen Ovale in Clinical Practice. Alkhouli M, Van Houten HK, Yao X, Holmes DR. Alkhouli M, et al. J Am Heart Assoc. 2023 Aug;12(15):e030321. doi: 10.1161/JAHA.123.030321. Epub 2023 Jul 25. J Am Heart Assoc. 2023. PMID: 37489748 Free PMC article.
A comparison of the effects of NOAC and VKA therapy on the incidence of dementia in patients with atrial fibrillation: A systematic review and meta-analysis.