![]() 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Only two have provided data for the wider population, 13 15 and only one of these presented results for the group without atrial fibrillation. Most well powered observational studies have also focused on patients with atrial fibrillation. These findings, therefore, represent only indirect comparisons between different types of DOACs, derived using network meta-analysis techniques. 11 The included studies were differently designed, and none provided data for all DOACs. A recent meta-analysis has shown that apixaban has advantages over warfarin, providing a better balance between efficacy and safety. These trials have established non-inferiority in the anticoagulating qualities of DOACs compared with warfarin in controlled trial settings, 8 9 10 but there are residual concerns regarding their safety, particularly in more real world settings, where they are prescribed to a broad range of patients. 6 7Ītrial fibrillation is the most common condition requiring anticoagulants, and most clinical trial evidence has been based on this group of patients. There are, however, some concerns regarding the safety of DOACs with respect to bleeding because there is an absence of or a limited choice of antidotes, some of which are also expensive. 5 They also have faster onset and offset of action. Unlike warfarin, these drugs have set doses and do not generally require regular international normalisation ratio blood test monitoring. 1 2 3 4 Warfarin has been used for six decades but in the last eight years its use has been gradually replaced by a new class of direct acting oral anticoagulants (DOACs) including dabigatran, rivaroxaban, and apixaban. Increased risk of all cause mortality was observed in patients taking rivaroxaban (1.51, 1.38 to 1.66) and those on lower doses of apixaban (1.34, 1.13 to 1.58).Īnticoagulants are used for the prevention and treatment of venous thromboembolism and to reduce the risk of stroke in patients with either atrial fibrillation or after acute pulmonary embolism, deep vein thrombosis, or hip or knee replacement surgery. In patients without atrial fibrillation, compared with warfarin, apixaban was associated with a decreased risk of major bleeding (0.60, 0.46 to 0.79), any gastrointestinal bleeding (0.55, 0.37 to 0.83), and upper gastrointestinal bleeding (0.55, 0.36 to 0.83) rivaroxaban was associated with a decreased risk of intracranial bleeding (0.54, 0.35 to 0.82). An increased risk of all cause mortality was observed in patients taking rivaroxaban (1.19, 1.09 to 1.29) or on lower doses of apixaban (1.27, 1.12 to 1.45). Results In patients with atrial fibrillation, compared with warfarin, apixaban was associated with a decreased risk of major bleeding (adjusted hazard ratio 0.66, 95% confidence interval 0.54 to 0.79) and intracranial bleeding (0.40, 0.25 to 0.64) dabigatran was associated with a decreased risk of intracranial bleeding (0.45, 0.26 to 0.77).
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