New research shows that direct oral anticoagulants (DOACs) are at least as safe and effective as warfarin (Coumadin)—and in some cases, more effective—in preventing thromboembolic complications in atrial fibrillation (AF).
The authors of the analysis, published in the Annals of Internal Medicine, reviewed 117 studies in several databases that had been reported between January 2000 and February 2018. The studies involved nearly 4 million patients with nonvalvular AF.
Angela Lowenstern, MD, with Duke University School of Medicine and her colleagues found that dabigatran (Pradaxa) and apixaban (Eliquis) were superior to warfarin in preventing stroke and systemic embolism.
Apixaban and edoxaban (Savaysa) were superior to warfarin in reducing major bleeding, while rivaroxaban (Xarelto) and dabigatran were similar to warfarin.
“Evidence suggests that DOACs are noninferior to warfarin in preventing thromboembolic complications and are generally superior to warfarin in reducing major bleeding events,” Lowenstern wrote.
The benefit of treatment with apixaban was consistent in many subgroups, including those with renal impairment, diabetes, and prior stroke, Lowenstern wrote. Patients who received apixaban were less likely to die within 30 days of a major hemorrhagic event than those who received warfarin or to have nonmajor bleeding, the researchers found.
Patients taking apixaban also had lower rates of intracranial hemorrhage.
However, the number of hospital admissions did not differ significantly between the apixaban and warfarin treatment groups.
Meanwhile, the large ROCKET-AF trial found that 20 mg daily rivaroxaban was noninferior to warfarin in preventing stroke or systemic embolism. “The rates of major bleeding and all-cause mortality also were similar between treatment groups,” Lowenstern wrote.
The ENGAGE-AF trial found that edoxaban at both 30 mg/day and 60 mg/day was noninferior to warfarin in preventing stroke or systemic embolism. “In addition, both edoxaban dosages reduced the risk for hemorrhagic stroke and rates of major bleeding compared with warfarin,” she wrote.
The analysis was commissioned by the Patient-Centered Outcomes Research Institute (PCORI) in partnership with the Evidence-based Practice Center Program of the Agency for Healthcare Research and Quality (AHRQ) as a means of exploring the data and ongoing uncertainties regarding AF treatment.