For efficacy – yes; for safety, apixaban is associated with somewhat less gastrointestinal bleeding.

Although randomised trials have shown that all four available direct- acting oral anticoagulants (DOACs;apixaban, dabigatran, edoxaban and rivaroxaban) prevent thromboembolic complications related to atrial fibrillation, less evidence is available to guide which DOAC to select. In a retrospective study, investigators accessed five electronic health databases from Europe and the USA to compare more than 500,000 new DOAC users with newly diagnosed atrial fibrillation. Follow up varied from 1.5 to 4.5 years.

In propensity score-adjusted analyses, patients who received apixaban had significantly less gastrointestinal (GI) bleeding than those who received any of the other three drugs (hazard ratios, 0.7 to 0.8). This result was consistent among older patients and those with chronic kidney disease (CKD). Risk for stroke or other systemic embolism, intracranial haemorrhage and all-cause mortality did not differ significantly among DOACs.

Comment: This is the largest comparison of individual DOACs, and it demonstrates similar efficacy among all agents. Although apixaban was associated with less GI bleeding, absolute percentages of GI bleeds ranged from about 2% to about 3.5% for all DOACs; therefore, apixaban’s statistically significant safety benefit might amount to marginal clinical benefit for any individual patient. I might turn to apixaban for patients at high risk for GI bleeding (and those with CKD), but all DOACs remain reasonable options for preventing thromboembolism in most patients with atrial fibrillation.
DANIEL D. DRESSLER, MD, MSc, MHM, FACP
Professor of Medicine, Emory University School of Medicine, Atlanta, USA.

Lau WCY, et al. Comparative effectiveness and safety between apixaban, dabigatran, edoxaban, and rivaroxaban among patients with atrial fibrillation: a multinational population-based cohort study. Ann Intern Med 2022 Nov 1; e-pub (https://doi.org/10.7326/M22-0511).  

This summary is taken from the following Journal Watch title: Neurology.