Among DOACs, only apixaban was associated with significantly lower risks of both stroke/systemic embolism (HR 0.40; 95% CI 0.31-0.53) and major bleeding compared to warfarin.
Cohort (n=186,132)
Do direct oral anticoagulants (apixaban, rivaroxaban, dabigatran) reduce the risk and cost of stroke/systemic embolism and major bleeding compared to warfarin in older patients with non-valvular atrial fibrillation?
In a real-world Medicare population, apixaban was the only DOAC associated with significantly lower risks of both stroke/systemic embolism and major bleeding, as well as lower related medical costs, compared to warfarin.
Effect estimate: HR 0.40 (95% CI 0.31-0.53)
OBJECTIVE: To compare the risk and cost of stroke/systemic embolism (SE) and major bleeding between each direct oral anticoagulant (DOAC) and warfarin among non-valvular atrial fibrillation (NVAF) patients. METHODS: Patients (≥65 years) initiating warfarin or DOACs (apixaban, rivaroxaban, and dabigatran) were selected from the Medicare database from 1 January 2013 to 31 December 2014. Patients initiating each DOAC were matched 1: 1 to warfarin patients using propensity score matching to balance demographics and clinical characteristics. Cox proportional hazards models were used to estimate the risks of stroke/SE and major bleeding of each DOAC vs. warfarin. Two-part models were used to compare the stroke/SE- and major-bleeding-related medical costs between matched cohorts. RESULTS: Of the 186, 132 eligible patients, 20, 803 apixaban-warfarin pairs, 52, 476 rivaroxaban-warfarin pairs, and 16, 731 dabigatran-warfarin pairs were matched. Apixaban (hazard ratio HR = 0. 40; 95% confidence interval CI 0. 31, 0. 53) and rivaroxaban (HR = 0. 72; 95% CI 0. 63, 0. 83) were significantly associated with lower risk of stroke/SE compared to warfarin. Apixaban (HR = 0. 51; 95% CI 0. 44, 0. 58) and dabigatran (HR = 0. 79; 95% CI 0. 69, 0. 91) were significantly associated with lower risk of major bleeding; rivaroxaban (HR = 1. 17; 95% CI 1. 10, 1. 26) was significantly associated with higher risk of major bleeding compared to warfarin. Compared to warfarin, apixaban (63 vs. 131) and rivaroxaban (93 vs. 139) had significantly lower stroke/SE-related medical costs; apixaban (292 vs. 529) and dabigatran (369 vs. 450) had significantly lower major bleeding-related medical costs. CONCLUSIONS: Among the DOACs in the study, only apixaban is associated with a significantly lower risk of stroke/SE and major bleeding and lower related medical costs compared to warfarin.
Amin et al. (2017) conducted a cohort in non-valvular atrial fibrillation (NVAF) (n=186,132). DOACs (apixaban, rivaroxaban, dabigatran) vs. warfarin was evaluated on stroke/systemic embolism (SE) (HR 0.40, 95% CI 0.31-0.53). Among DOACs, only apixaban was associated with significantly lower risks of both stroke/systemic embolism (HR 0.40; 95% CI 0.31-0.53) and major bleeding compared to warfarin.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: