For the first time all direct acting oral anticoagulants currently licensed for prevention of stroke in people with atrial fibrillation have been ranked in terms of both individual efficacy and safety outcomes and overall cost effectiveness.
Despite their higher costs, several are preferable to warfarin as an initial treatment choice, with apixaban (Eliquis) ranking highest on the balance of efficacy, safety and cost, the new analysis suggests.
The systematic review published in the BMJ found that direct acting oral anticoagulants (DOACs) as a class reduce the risk of stroke and all-cause mortality in patients with atrial fibrillation, and are safer with respect to major and intracranial bleeding than warfarin when used at doses to maintain an international normalised ratio of 2.0-3.0.
Using data from 23 randomised trials involving almost 95,000 patients, the UK-based team found that apixaban 5 mg twice daily has the highest expected incremental net benefit, followed by rivaroxaban 20 mg once daily, edoxaban 60 mg once daily and dabigatran 150 mg twice daily.
One of the researchers Jonathan Sterne, Professor of Medical Statistics and Epidemiology at the University of Bristol, said that while DOACs are already widely used instead of warfarin despite their higher cost, no trials have directly compared different DOACs with each other and so it has been difficult to determine which drug should be recommended as a first choice for most patients.
He hopes the new findings will help policy makers, clinicians and patients make an informed choice between the different available DOACs based on efficacy, safety and cost effectiveness.
“It’s hard to predict what influence our findings will have – we hope that they will influence local and national treatment guidelines as well as individual healthcare professionals. And we hope that patients trying to understand treatment options will find our paper useful,” he told the limbic.
Professor Sterne says that the main limitation of the analysis is the lack of a direct comparison of different DOACs in a randomised trial, which has meant relying on indirect comparisons made through network meta-analyses.
Additional investments in new head-to-head trials may help practitioners and policy makers better understand the role of DOACs in this clinical setting, the researchers note.