Comparison of the Non-VKA Oral Anticoagulants Apixaban, Dabigatran, and Rivaroxaban in the Extended Treatment and Prevention of Venous Thromboembolism: Systematic Review and Network Meta-Analysis
Key result
NOACs significantly reduced the risk of VTE and VTE-related death compared with aspirin, with apixaban demonstrating the most favorable bleeding profile compared with other NOACs, warfarin, and aspirin.
Why the study?
Do NOACs reduce VTE and VTE-related death compared to aspirin, warfarin, or placebo in adults requiring extended treatment of VTE?
Population
Adults with an objectively confirmed deep vein thrombosis, pulmonary embolism or both requiring extended…
Comparison
Non-VKA oral anticoagulants as a class… vs Aspirin, warfarin (target INR 2.0-3.0), or placebo
Design
Meta-analysis
Follow-up
>3 months
Authors
Discussion
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Implication
Supports NOAC preference over aspirin for extended VTE prevention; extends prior trials by ranking apixaban's superior bleeding safety.
Study Design
Type
Network Meta-Analysis
Structured PICO
Do NOACs reduce VTE and VTE-related death compared to aspirin, warfarin, or placebo in adults requiring extended treatment of VTE?
P
Population
Adults ≥18 years of age who had received prior treatment for an initial VTE event, included in 11 Phase III RCTs evaluating extended anticoagulation.
I
Intervention
Non-VKA oral anticoagulants (NOACs) as a class, specifically apixaban, dabigatran, and rivaroxaban
C
Comparator
Aspirin, warfarin (target INR 2.0-3.0), or placebo
O
Outcome
Composite efficacy outcome of VTE and VTE-related deathcomposite
Main Result
Relative Risk: 0.28 (95% CI 0.14–0.51)
NOACs are effective for the extended prevention of VTE, with apixaban demonstrating the most favorable bleeding safety profile among oral anticoagulants.
Limitations
- Small number of studies in the network and low event numbers leading to high uncertainty for some treatment comparisons.
- Variation in the baseline risk of VTE across trials due to differences in time since the initial VTE event and duration of extended treatment.
- Results for VTE and VTE-related death were sensitive to the dataset used (intended treatment period vs. intended follow-up period).
- Results were dependent on the dataset employed according to the time frame for outcome assessment
Cite This Study
Cohen et al. (2016) conducted a network meta-analysis in Venous Thromboembolism (VTE). Non-VKA oral anticoagulants (apixaban, dabigatran, rivaroxaban) vs. Aspirin, warfarin INR 2.0-3.0, or placebo was evaluated on Composite of VTE and VTE-related death (Apixaban vs. Aspirin comparison) (RR 0.28, 95% CI 0.14-0.51). NOACs significantly reduced the risk of VTE and VTE-related death compared with aspirin, with apixaban demonstrating the most favorable bleeding profile compared with other NOACs, warfarin, and aspirin.