Apixaban beats other oral anticoagulants in AF plus cirrhosis

Coagulation

By Mardi Chapman

11 Jul 2024

Apixaban appears safer than either rivaroxaban or warfarin to prevent stroke in patients with atrial fibrillation (AF) and established cirrhosis, new research suggests.

A US study, published in Annals of Internal Medicine [link here], found rivaroxaban or warfarin use was associated with higher rates of major haemorrhage than apixaban and similar rates of major ischaemic events.

The findings have important clinical implications given that patients with cirrhosis were excluded from all previous major RCTs of oral anticoagulants for AF.

The retrospective study used data from two large commercial healthcare insurance databases to identify patients with cirrhosis and AF who filled an initial prescription for apixaban or rivaroxaban at either the standard or reduced dose or warfarin between 1 January 2013 and 31 December 2020 or 31 March 2022, depending on the database.

Patients were propensity-matched to emulate trials of either rivaroxaban versus apixaban or warfarin versus apixaban.

It found rivaroxaban initiators had a significantly higher incidence of major haemorrhagic events than apixaban initiators (86.9 v 51.0 per 1000 person-years; HR 1.47 [CI, 1.11 to 1.94]).

There were also significantly higher absolute rates of major GI bleeding events with rivaroxaban than with apixaban.

In subgroup analyses, the absolute rates of major haemorrhagic events were significantly higher with rivaroxaban than apixaban among patients with decompensated cirrhosis but not in those with compensated cirrhosis.

“Our results show that in patients with cirrhosis and AF, apixaban might be preferable to rivaroxaban due to substantially lower rates of major haemorrhagic events and similar rates of major ischaemic events.”

The study also found initiators of warfarin had modestly but statistically significantly higher rates of major haemorrhagic events compared with initiators of apixaban (78.9 vs. 50.6 per 1000 person-years; HR, 1.38 [CI, 1.03 to 1.84]).

This included significantly higher rates of haemorrhagic stroke (HR, 2.85 [CI, 1.24 to 6.59]), the study said.

In subgroup analyses, the absolute rates of major haemorrhagic events were significantly higher with warfarin than apixaban in patients with decompensated and compensated cirrhosis.

The incidence of ischaemic events appeared to be similar among all groups.

“Our data further suggest that apixaban might also be preferable to warfarin because of reduced major bleeding events, including lower rates of major haemorrhagic stroke, and similar rates of ischaemic events.”

“To our knowledge, this is the first study to directly compare the most commonly prescribed OACs (apixaban, rivaroxaban, and warfarin) in patients with cirrhosis and AF, a growing population that lacks sufficient data to guide treatment selection,” the investigators said.

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