Apixaban appears safer than rivaroxaban, warfarin in cirrhosis with atrial fibrillation
Patients who initiated rivaroxaban or warfarin had significantly higher rates of major hemorrhagic events than those taking apixaban, a retrospective study of U.S. patients with cirrhosis and nonvalvular atrial fibrillation found.
For patients with cirrhosis and nonvalvular atrial fibrillation, apixaban may offer safety benefits compared with rivaroxaban or warfarin, a study found.
Researchers used two sets of U.S. claims data to propensity score match patients with cirrhosis and nonvalvular atrial fibrillation who were starting apixaban, rivaroxaban, or warfarin and determine rates of ischemic stroke or systemic embolism and major hemorrhage (intracranial hemorrhage or major gastrointestinal bleeding). The study was published July 9 by Annals of Internal Medicine.
Patients starting rivaroxaban treatment had significantly higher rates of major hemorrhagic events than those receiving apixaban (rate difference [RD], 33.1 per 1,000 person-years [95% CI, 12.9 to 53.2]; hazard ratio [HR], 1.47 [95% CI, 1.11 to 1.94]) but no significant difference in death. Rates of major hemorrhage were consistently higher with rivaroxaban across subgroup and sensitivity analyses. Warfarin also had significantly higher rates of major hemorrhage than apixaban (RD, 26.1 per 1,000 person-years [95% CI, 6.8 to 45.3]; HR, 1.38 [95% CI, 1.03 to 1.84]), particularly hemorrhagic stroke (RD, 9.7 per 1,000 person-years [95% CI, 2.2 to 17.2]; HR, 2.85 [95% CI, 1.24 to 6.59]). The incidence of ischemic events was similar among all groups.
Apixaban may offer greater relative safety, a finding that could guide clinical care for a patient population that has lacked sufficient data to inform treatment selection, the study authors wrote. Warfarin is challenging to use in advanced liver disease because cirrhosis is frequently accompanied by coagulopathy and because of potential drug-drug interactions, they noted. No head-to-head trials focused on cirrhosis have directly compared anticoagulants, leaving clinicians without clear guidance.
"However, although these findings are noteworthy, careful treatment selection must consider all risks, benefits, and alternatives; accordingly, future studies, including clinical trials, are still needed that compare all [direct-acting oral anticoagulants] with one another, with warfarin, and with no anticoagulation across the full spectrum of disease," the authors cautioned.