Indirect comparison of novel Oral anticoagulants among Asians with non-Valvular atrial fibrillation in the real world setting: a network meta-analysis

BACKGROUND: The development of novel oral anticoagulants (NOACs) has changed the landscape of non-valvular atrial fibrillation (NVAF) management. In this study, the effectiveness and the safety of several NOACs were evaluated in a real-world setting among Asian patients with NVAF. METHODS: The literature search was conducted crossing different databases including Embase, MEDLINE, and the Cochrane Library from inception through March 1, 2019, for studies which included real-world perspectives comparing the individual NOACs with each other or with warfarin among Asians with NVAF. The primary outcomes were defined as stroke or systemic embolism (SSE) and major bleeding; ischemic stroke, all-cause death as well as intracranial bleeding were classified as the secondary outcomes. RESULTS: From sixteen real-world studies, a total of 312,827 Asian patients were included in this analysis. In comparison with warfarin, the utilization of apixaban, dabigatran, and rivaroxaban significantly lowered the risk of major bleeding (apixaban: HR 0.47, 95%CI 0.35-0.63; dabigatran: HR 0.59, 95%CI 0.47-0.73; rivaroxaban: HR 0.66, 95%CI 0.52-0.83) and lessened the all-cause death rate (apixaban: HR 0.29, 95%CI 0.16-0.52; dabigatran: HR 0.40, 95%CI 0.27-0.60; rivaroxaban: HR 0.42, 95%CI 0.28-0.65). Apixaban (HR 0.59; 95%CI 0.40-0.85) reduced the possibility of ischemic stroke when compared against dabigatran. Rivaroxaban showed a higher chance of causing an ischemic stroke (HR 1.61; 95%CI 1.08-2.41) and major bleeding (HR 1.39; 95%CI 1.02-1.90) than Apixaban. CONCLUSIONS: Apixaban, dabigatran and rivaroxaban were more effective than warfarin on reducing the risks of stroke and haemorrhage; meanwhile, apixaban was likely to lower the risk of major bleeding comparing to rivaroxaban. TRIAL REGISTRATION: PROSPERO registry number: CRD42018086914 .