No studies have performed direct pairwise comparisons of the effectiveness and safety
of warfarin and the new oral anticoagulants (NOACs) apixaban, dabigatran, and rivaroxaban.
Using 2013 to 2014 claims from a 5% random sample of Medicare beneficiaries, we identified
patients newly diagnosed with atrial fibrillation who initiated apixaban, dabigatran,
rivaroxaban, warfarin, or no oral anticoagulation therapy in 2013 to 2014. Outcomes
included the composite of ischemic stroke, systemic embolism (SE) and death, any bleeding
event, gastrointestinal bleeding, intracranial bleeding, and treatment persistence.
We constructed Cox proportional hazard models to compare outcomes between each pair
of treatment groups. The composite risk of ischemic stroke, SE, and death was lower
for NOACs than for warfarin: hazard ratio (HR) 0.86, 95% confidence interval (CI)
0.76 to 0.98 for apixaban; 0.73, 95% CI 0.63 to 0.86 for dabigatran; and 0.82, 95%
CI 0.75 to 0.89 for rivaroxaban, all compared with warfarin. There were no differences
in effectiveness across NOACs. The risk of any bleeding was lower with apixaban than
with warfarin, but higher with rivaroxaban than with warfarin. Apixaban (HR 0.69,
95% CI 0.60 to 0.79) and dabigatran (HR 0.79, 95% CI 0.69 to 0.92) were associated
with lower bleeding risk than rivaroxaban. Treatment persistence was highest for apixaban
(82%), and lowest for dabigatran and warfarin (64%) (p value <0.001). Compared with
warfarin, NOACs are more effective in preventing stroke but their risk of bleeding
varies, with rivaroxaban having higher risk than warfarin. Altogether, apixaban had
the most favorable effectiveness, safety, and persistence profile.
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Article info
Publication history
Published online: August 08, 2017
Accepted:
July 24,
2017
Received:
May 5,
2017
Footnotes
We acknowledge funding from the Commonwealth Fund (Grant numbers 20150380 and 20160326).
See page 1818 for disclosure information.
Identification
Copyright
© 2017 Elsevier Inc. All rights reserved.
