Key result
An indirect comparison of 16 RCTs found no significant difference in the risk of recurrent VTE or major bleeding among dabigatran, rivaroxaban, apixaban, and edoxaban in patients with acute VTE.
Why the study?
There is no direct comparison from clinical trials among direct oral anticoagulants in patients with acute venous thromboembolism, leaving an evidence gap for clinical decision-making.
Is there a difference in efficacy and safety among direct oral anticoagulants in patients with acute venous thromboembolism?
Systematic Review (n=48,007)
Is there a difference in efficacy and safety among direct oral anticoagulants in patients with acute venous thromboembolism?
Indirect comparisons suggest no significant differences in efficacy or safety among the four DOACs for treating acute VTE, highlighting the need for direct head-to-head trials.
Supports equivalent DOAC selection in acute VTE based on patient factors; confirms similar efficacy and safety but with low-quality evidence.
Background: There is no direct comparison from clinical trials amongst the direct oral anticoagulants (DOACs) in patients with acute venous thromboembolism (VTE), leaving an evidence gap in decision-making regarding the choice of a DOAC. Methods: We performed a systematic review for an indirect comparison from randomized controlled trials (RCTs) for comparative effects amongst DOACs in the patients with acute VTE. Results: A total of 16 RCTs were included for analyses, among which 3 for dabigatran (n = 7,963 patients), 6 rivaroxaban (n = 17,935), 5 apixaban (n = 12,823), and 2 edoxaban (n = 9,286). There was no significant difference in risk of recurrent VTE (evidence quality: low) and major bleeding (evidence quality: very low) for treatment effects between the four DOACs. Albeit non-significantly, apixaban seemed to have a lowest risk of major bleeding while rivaroxaban had a smallest risk of VTE. Although in general all the included trials were comparable, data from the included trials indicated that the assumption of transitivity may be challenged. Further methodological research including simulation studies, using a net-benefit or benefit-harm approach, running ranking probability analysis, and developing decision aids with machine-learning may be a worthwhile endeavor to help with the choice of DOACs in patients with acute VTE. Conclusions: To conclude, based on results from the indirect comparison no significant difference in the efficacy and safety was found among the DOACs in patients with acute VTE. More evidence from direct comparative trials is needed to further inform the choice of DOACs in patients with acute VTE.
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Li et al. (2020) conducted a systematic review in acute venous thromboembolism (n=48,007). Direct oral anticoagulants vs. Other direct oral anticoagulants was evaluated on Recurrent VTE and major bleeding. An indirect comparison of 16 RCTs found no significant difference in the risk of recurrent VTE or major bleeding among dabigatran, rivaroxaban, apixaban, and edoxaban in patients with acute VTE.
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