Efficacy and Safety of Direct Oral Anticoagulants in Patients with Diabetes and Nonvalvular Atrial Fibrillation: Meta-Analysis of Observational Studies

Abstract

Background. This meta-analysis was performed to compare the efficacy and safety of direct oral anticoagulants (DOACs) with vitamin K antagonists (VKAs) for stroke prevention in real-world patients with diabetes and nonvalvular atrial fibrillation (NVAF) through observational studies. Methods. PubMed, Embase, and Web of Science databases were searched up to August 2020 for eligible studies. Outputs were presented as risk ratios (RRs) and corresponding 95% confidence intervals (CIs) by using a random-effect model. Results. Seven observational studies involving 249,794 diabetic NVAF patients were selected. Compared with VKAs, the use of DOACs was associated with significantly reduced risks of stroke ( RR = 0.56 , 95% CI 0.45-0.70; p < 0.00001 ), ischemic stroke ( RR = 0.61 , 95% CI 0.48-0.78; p < 0.0001 ), stroke or systemic embolism (SSE) ( RR = 0.81 , 95% CI 0.68-0.95; p = 0.01 ), myocardial infarction ( RR = 0.69 , 95% CI 0.55-0.88; p = 0.002 ), major bleeding ( RR = 0.75 , 95% CI 0.63-0.90; p = 0.002 ), intracranial hemorrhage ( RR = 0.50 , 95% CI 0.44-0.56; p < 0.00001 ), and major gastrointestinal bleeding ( RR = 0.77 , 95% CI 0.62-0.95; p = 0.02 ), and a borderline significant decrease in major adverse cardiac events ( RR = 0.87 , 95% CI 0.75-1.00; p = 0.05 ) in NVAF patients with diabetes. Conclusion. For patients with NVAF and diabetes in real-world clinical settings, DOACs showed superior efficacy and safety profile over VKAs and significantly reduced risks of stroke, ischemic stroke, SSE, myocardial infarction, major bleeding, intracranial hemorrhage, and major gastrointestinal bleeding.

Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review

“…Evidence from RCTs suggests that patients with diabetes benefit from DOAC versus VKA therapy to an extent similar to patients without diabetes [ 86 , 87 ]. A recent meta-analysis of observational studies reported that DOACs had a superior efficacy and safety profile over VKAs in patients with NVAF and diabetes [ 88 ]. Interestingly, a recent observational nationwide study has shown that DOACs were associated with a lower risk of diabetes vascular complications and mortality than warfarin in patients with AF and diabetes [ 89 ].…”

Platelet–Neutrophil Interaction and Thromboinflammation in Diabetes: Considerations for Novel Therapeutic Approaches

“… 72 For instance, a meta‐analysis comparing the effects of direct oral anticoagulants with vitamin K antagonists, such as warfarin, in patients with diabetes and atrial fibrillation showed that direct oral anticoagulants were more efficacious at preventing stroke, MI, and major bleeding. 73 Results from the rivaroxaban once daily oral direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation trial, however, showed similar relative efficacy of warfarin and rivaroxaban for stroke prevention in >5000 patients with T2D with atrial fibrillation. 74 A recent review provides further insight on antithrombotic therapy in diabetes.…”

Clinical Impact of Switching or Continuation of Apixaban or Rivaroxaban among Patients with Non-Valvular Atrial Fibrillation

“…Direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, and rivaroxaban are now the standard of care for stroke prevention in NVAF patients in the US [8][9][10][11][12][13]. DOACs are more convenient for patients and have similar or better efficacy and safety than warfarin [8,14].…”