Indirect comparison of novel Oral anticoagulants among Asians with non-Valvular atrial fibrillation in the real world setting: a network meta-analysis

Abstract

Background The development of novel oral anticoagulants (NOACs) has changed the landscape of non-valvular atrial fibrillation (NVAF) management. In this study, the effectiveness and the safety of several NOACs were evaluated in a real-world setting among Asian patients with NVAF. Methods The literature search was conducted crossing different databases including Embase, MEDLINE, and the Cochrane Library from inception through March 1, 2019, for studies which included real-world perspectives comparing the individual NOACs with each other or with warfarin among Asians with NVAF. The primary outcomes were defined as stroke or systemic embolism (SSE) and major bleeding; ischemic stroke, all-cause death as well as intracranial bleeding were classified as the secondary outcomes. Results From sixteen real-world studies, a total of 312,827 Asian patients were included in this analysis. In comparison with warfarin, the utilization of apixaban, dabigatran, and rivaroxaban significantly lowered the risk of major bleeding (apixaban: HR 0.47, 95%CI 0.35–0.63; dabigatran: HR 0.59, 95%CI 0.47–0.73; rivaroxaban: HR 0.66, 95%CI 0.52–0.83) and lessened the all-cause death rate (apixaban: HR 0.29, 95%CI 0.16–0.52; dabigatran: HR 0.40, 95%CI 0.27–0.60; rivaroxaban: HR 0.42, 95%CI 0.28–0.65). Apixaban (HR 0.59; 95%CI 0.40–0.85) reduced the possibility of ischemic stroke when compared against dabigatran. Rivaroxaban showed a higher chance of causing an ischemic stroke (HR 1.61; 95%CI 1.08–2.41) and major bleeding (HR 1.39; 95%CI 1.02–1.90) than Apixaban. Conclusions Apixaban, dabigatran and rivaroxaban were more effective than warfarin on reducing the risks of stroke and haemorrhage; meanwhile, apixaban was likely to lower the risk of major bleeding comparing to rivaroxaban. Trial registration PROSPERO registry number: CRD42018086914 . Electronic supplementary material The online version of this article (10.1186/s12872-019-1165-5) contains supplementary material, which is available to authorized users.

Comparison of readmissions among hospitalized nonvalvular atrial fibrillation patients treated with oral anticoagulants in the United States

“…For this study we specifically were concerned with hospital readmission outcomes, but our findings between the warfarin and apixaban cohorts and the rivaroxaban and apixaban cohorts provide further evidence that apixaban treatment may be associated with better clinical outcomes than these other OACs. These findings are aligned with those of several real-world evidence studies [9][10][11][12][13][14][15][16][17][18][19] , as well as network meta-analyses of clinical trial data 23,24 , in which all have generally found apixaban to have the better safety profile (i.e. lowest bleeding risk) compared to other OACs.…”

“…A network meta-analysis published in 2018 of 11 studies conducted in the real-world setting has summarized that, of the OACs (warfarin, dabigatran, rivaroxaban, and apixaban), apixaban is associated with the lowest risk for MB (apixaban vs warfarin hazard ratio [HR] ¼ 0.58; 95% confidence interval [CI] ¼ 0.48-0.69; apixaban vs dabigatran HR ¼ 0.73; 95% CI ¼ 0.61-0.87; apixaban vs rivaroxaban HR ¼ 0.55; 95% CI ¼ 0.46-0.66) 15 . Directionally consistent results in regard to bleeding outcomes have been reported in other meta-analyses of real-world data [16][17][18][19] .…”

“…Furthermore, depending on the DOAC investigated in the clinical trial, they were associated with lower or similar rates of bleeding relative to warfarin [6][7][8] . Other studies conducted in the real-world setting have more recently provided evidence that apixaban is associated with lower risks for stroke and major bleeding (MB) than warfarin, as well as lower risks for MB than rivaroxaban and dabigatran; although there is some variation in the results regarding the DOAC comparisons [9][10][11][12][13][14][15][16][17][18][19] . A network meta-analysis published in 2018 of 11 studies conducted in the real-world setting has summarized that, of the OACs (warfarin, dabigatran, rivaroxaban, and apixaban), apixaban is associated with the lowest risk for MB (apixaban vs warfarin hazard ratio [HR] ¼ 0.58; 95% confidence interval [CI] ¼ 0.48-0.69; apixaban vs dabigatran HR ¼ 0.73; 95% CI ¼ 0.61-0.87; apixaban vs rivaroxaban HR ¼ 0.55; 95% CI ¼ 0.46-0.66) 15 .…”

Stroke and Bleeding Risks in Patients with Atrial Fibrillation Treated with Reduced Apixaban Dose: A Real‐Life Study

“…A better safety profile was found with apixaban compared with warfarin. 8,9 In the ARISTOTLE trial subgroup analyses, adjusted reduced dose of 2.5 mg twice a day (b.i.d.) of apixaban was as effective as warfarin for stroke prevention, and was associated with lower bleeding.…”

Time to develop guidelines for screening and management of atrial fibrillation in Indigenous Australians

“…Finally, anticoagulation decisions must take the higher intracranial haemorrhage rates of Indigenous Australians into account . Treatment with NOACs may be safer than with warfarin, as trials in Asian populations with similarly high intracranial haemorrhage risk have found that their rate is reduced by about 50% in patients receiving NOACs . Unfortunately, evidence about the safety of NOACs for Indigenous Australians is scarce.…”