Bleeding risk on rivaroxaban versus apixaban in older patients with venous thromboembolism: a nationwide observational register-based study

Comparative data on the bleeding risk in cancer-free patients aged ≥65 years treated with rivaroxaban or apixaban for venous thromboembolism is scarce. The aim was to compare major bleeding rates between rivaroxaban and apixaban during primary treatment (0 - 6 months) and secondary treatment (6 months - 5 years). Additionally, all-cause mortality and recurrent pulmonary embolism (PE) were assessed. A register-based cohort study of cancer-free patients in Sweden aged ≥65 years with a first-time PE or deep vein thrombosis and a filled prescription of rivaroxaban or apixaban between January 1, 2014, and July 1, 2023. Cox proportional hazard models were used to compare rates of bleeding, all-cause mortality, and recurrent PE. 19,090 patients were included; 7572 on rivaroxaban and 11,518 on apixaban. During primary treatment, rates of major bleeding were 4.4 (95 % confidence interval (CI) 3.7-5.2) per 100 patient-years on rivaroxaban and 3.3 (2.8-3.9) on apixaban, adjusted hazard ratio (aHR) 1.46 (1.15-1.85). During secondary treatment, major bleeding rates were 1.4 (1.2-1.7) per 100 patient-years on rivaroxaban and 1.2 (1.0-1.5) on apixaban, aHR 1.24 (0.94-1.63). No difference was seen in recurrent PE, however, a higher mortality was seen for patients on rivaroxaban. During primary treatment, apixaban was associated with a lower risk of major bleeding than rivaroxaban without a corresponding increase in recurrent PE risk. During secondary treatment, no difference in bleeding risk was observed. The Swedish Heart and Lung Foundation. The Swedish State under the agreement between the Swedish Government and the county councils.