What does this research mean for the field?

Switching from apixaban to rivaroxaban after a bleeding event increases the risk of major bleeding compared to persisting with apixaban. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This research aims to understand the impact of switching or persisting with direct oral anticoagulants after a bleeding event in atrial fibrillation patients.

January 21, 2026Journal of the American Heart Association0 citationsOpen Access

Clinical Impact of Switching From or Persisting With Rivaroxaban or Apixaban After a Bleeding Event: A Real‐World Study in Patients With Nonvalvular Atrial Fibrillation

GLGregory Y. H. LipMedical University of Białystok DCDong ChengBristol-Myers Squibb (Germany)JJJenny JiangBristol-Myers Squibb (Germany)

Key Result

Switching from apixaban to rivaroxaban after a bleeding event increased the risk of major bleeding (HR 1.690) compared to persisting with apixaban.

Key Points

This research aims to understand the impact of switching or persisting with direct oral anticoagulants after a bleeding event in atrial fibrillation patients.
Conducted a retrospective observational study using US claims data from 2012 to 2024.
Included adults with nonvalvular atrial fibrillation who had a bleeding claim after initiating a DOAC.
Compared outcomes for patients who switched DOACs versus those who continued with the same DOAC using propensity score matching.
Among 59,620 apixaban initiators and 21,004 rivaroxaban initiators, 408 switchers were matched to 2040 persistent users for apixaban and 901 switchers to 4505 persistent users for rivaroxaban.
Apixaban-to-rivaroxaban switching had a higher risk of major bleeding (HR 1.690) with similar stroke risk (HR 1.793).
Rivaroxaban-to-apixaban switching had a lower risk of major bleeding (HR 0.651) with similar stroke risk (HR 0.783).

Structured PICO

Does switching DOACs compared to persisting with the same DOAC reduce major bleeding or stroke/systemic embolism in patients with nonvalvular atrial fibrillation who experience a bleeding event?

Population

80,624 adults (aged ≥18 years) with nonvalvular atrial fibrillation (59,620 apixaban initiators and 21,004 rivaroxaban initiators) who experienced a bleeding event while on DOAC therapy. US-based claims data. Excluded: warfarin first claim, valvular heart disease, VTE, hip/knee replacement, and pregnancy.

Intervention

Switching to a different DOAC (apixaban-to-rivaroxaban or rivaroxaban-to-apixaban) within 90 days of the index bleeding event.

Comparator

Persisting with the same index DOAC (apixaban or rivaroxaban) for ≥90 days after the index bleeding event.

Outcome

Major bleeding (comprising gastrointestinal bleeding, intracranial hemorrhage, and major bleeding at other sites) identified from inpatient claims.safety

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Background Real‐world research has identified differences in effectiveness and safety between direct oral anticoagulants (DOACs) when used to reduce risks of stroke and systemic embolism in patients with atrial fibrillation. However, treatment decisions and subsequent outcomes are poorly understood in patients with atrial fibrillation who experience bleeding when receiving a DOAC. Methods A retrospective observational study was conducted using US claims data from Optum’s Clinformatics Data Mart Database (January 2012 through March 2024). The study population comprised adults with nonvalvular atrial fibrillation who initiated a DOAC and had a subsequent claim for bleeding. After propensity score matching, patients who persisted with the same DOAC after bleeding were compared with those who switched to another DOAC. The main outcomes were major bleeding and stroke/systemic embolism. Results Among 59 620 apixaban initiators and 21 004 rivaroxaban initiators with bleeding while on therapy, 408 apixaban‐to‐rivaroxaban switchers were matched with 2040 persistent apixaban users, and 901 rivaroxaban‐to‐apixaban switchers were matched with 4505 persistent rivaroxaban users. Compared with persisting with apixaban following a bleeding event, apixaban‐to‐rivaroxaban switching was associated with a higher risk of major bleeding (hazard ratio HR, 1.690 95% CI, 1.130–2.527) and a similar risk of stroke/systemic embolism (HR, 1.793 95% CI, 0.765–4.202). Compared with persisting with rivaroxaban, rivaroxaban‐to‐apixaban switching was associated with a lower risk of major bleeding (HR, 0.651 95% CI, 0.460–0.920) and a similar risk of stroke/systemic embolism (HR, 0.783 95% CI, 0.371–1.652). Conclusions These findings suggest that the choice of DOAC after a bleeding event can affect treatment outcomes in patients with atrial fibrillation.

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