Real-world effectiveness and safety of apixaban versus rivaroxaban in pancreatic cancer–associated VTE.

739 Background: Pancreatic cancer is highly associated with venous thromboembolism (VTE), requiring long-term anticoagulation. However, evidence comparing outcomes between apixaban and rivaroxaban in this population remains limited. Methods: Using the TriNetX US Collaborative Network (71 healthcare organizations), we identified adults with pancreatic cancer and VTE treated with either apixaban or rivaroxaban. After propensity score matching, two balanced cohorts were generated (n=3,282 each). Kaplan–Meier survival analyses evaluated mortality, gastrointestinal (GI) bleeding, intracranial bleeding, recurrent pulmonary embolism (PE), deep vein thrombosis (DVT), and stroke. Hazard ratios (HRs) with 95% confidence intervals (CIs) and log-rank tests were reported. Results: Mortality was significantly lower in the apixaban group compared with rivaroxaban (median survival 1504 vs 343 days; HR 0.52, 95% CI 0.48–0.56, p<0.001). Risks of upper/lower GI bleeding were modestly lower with apixaban (12.7% vs 13.6%, HR 0.84, 95% CI 0.74–0.96, p=0.012). Intracranial bleeding rates were low and similar between groups (HR 1.24, 95% CI 0.76–2.01, p=0.395). Recurrent PE (HR 1.02, 95% CI 0.94–1.10, p=0.677) and DVT (HR 0.96, 95% CI 0.88–1.05, p=0.345) did not differ significantly. Stroke incidence was lower with apixaban (5.2% vs 7.2%, HR 0.67, 95% CI 0.55–0.81, p<0.001). Conclusions: In pancreatic cancer patients with VTE, apixaban was associated with lower mortality, reduced risk of stroke, and fewer GI bleeding events compared with rivaroxaban, while rates of PE, DVT, and intracranial bleeding were comparable. These findings suggest apixaban may provide a more favorable risk-benefit profile in this high-risk population.