In a large-scale comparison of direct oral anticoagulants (DOACs; visual abstract available) in routine clinical practice, apixaban had the lowest risk for gastrointestinal bleeding (GIB) in patients with atrial fibrillation (AF) while producing efficacy outcomes similar to those of dabigatran, edoxaban, and rivaroxaban. “This finding was consistent for patients aged 80 years or older and those with chronic kidney disease, who are often underrepresented in clinical trials,” the researchers conclude.
The data come from 5 standardized electronic healthcare databases in France, Germany, the U.K., and the U.S. Patients newly diagnosed with AF and treated with a DOAC had these outcomes in 2010–19 for database-specific hazard ratios (HRs) of ischemic stroke or systemic embolism, intracranial hemorrhage, GIB, and all-cause mortality: “A total of 527,226 new DOAC users met the inclusion criteria (apixaban, n = 281,320; dabigatran, n = 61,008; edoxaban, n = 12,722; and rivaroxaban, n = 172,176). Apixaban use was associated with lower risk for GIB than use of dabigatran (HR, 0.81 [95% CI, 0.70 to 0.94]), edoxaban (HR, 0.77 [CI, 0.66 to 0.91]), or rivaroxaban (HR, 0.72 [CI, 0.66 to 0.79]). No substantial differences were observed for other outcomes or DOAC–DOAC comparisons. The results were consistent for patients aged 80 years or older. Consistent associations between lower GIB risk and apixaban versus rivaroxaban were observed among patients receiving the standard dose (HR, 0.72 [CI, 0.64 to 0.82]), those receiving a reduced dose (HR, 0.68 [CI, 0.61 to 0.77]), and those with chronic kidney disease (HR, 0.68 [CI, 0.59 to 0.77]).”