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Review: Direct oral anticoagulants as safe, effective as warfarin
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Direct oral anticoagulants were similar or better in safety and efficacy vs. warfarin in patients with nonvalvular atrial fibrillation, according to a systematic review published in the Annals of Internal Medicine.
Angela Lowenstern, MD, from Duke University School of Medicine, and colleagues analyzed 220 articles covering 117 studies of 3,934,374 patients with nonvalvular AF. Outcomes of interest included prevention of stroke/systemic embolism and risk for major bleeding.
According to the researchers, for prevention of stroke/systemic embolism, dabigatran (Pradaxa, Boehringer Ingelheim) and apixaban (Eliquis, Bristol-Myers Squibb/Pfizer) were superior to warfarin, whereas rivaroxaban (Xarelto, Janssen/Bayer) and edoxaban (Savaysa, Daiichi Sankyo) were similar to warfarin.
Regarding risk for major bleeding, apixaban and edoxaban were superior vs. warfarin and dabigatran and rivaroxaban were similar to warfarin, the researchers wrote.
For dabigatran, the treatment effect was similar regardless of renal function (P for interaction > .05) and reduced bleeding rates were observed in patients younger than 75 years vs. patients aged 75 years or older (P for interaction < .001), Lowenstern and colleagues found.
For apixaban, the treatment effect was consistent across most subgroups, including according to renal function, diabetes status and prior stroke (P for interaction for all > .05), and reduction in bleeding risk associated with apixaban was most prominent in patients with glomerular filtration rate less than 50 mL/min/1.73 m2 (P = .003).
Apixaban also conferred lower major bleeding rates in patients without diabetes vs. patients with diabetes (P = .003), according to the researchers.
For rivaroxaban and edoxaban, treatment effect did not differ by stroke, diabetes or HF status (P for interaction for all > .05), Lowenstern and colleagues wrote.
The researchers also found that “[left atrial appendage] closure devices decrease the risk for major bleeding and show a trend toward a lower risk for stroke but with higher rates of procedural adverse events, such as serious pericardial effusion, major bleeding and device embolization.”
“Ongoing analyses are needed to understand how these newer treatment options compare in terms of therapeutic advantage as well as which patient populations might benefit most from each approach,” the researchers concluded. – by Erik Swain
Disclosures: Lowenstern reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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