DOACs vs Warfarin: Which Is More Effective For Stroke Prevention?

Apixaban administered twice daily at 5 mg might be the most effective and safest alternative to warfarin for the prevention of stroke among patients with atrial fibrillation, according to the findings of a recent study.

For their systematic review and meta-analysis, the researchers ranked the efficacy, safety, and cost-effectiveness of direct oral anticoagulants (DOACs) compared with warfarin for the prevention of stroke using data from 23 randomized trials that included 94656 patients with atrial fibrillation.
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Compared with warfarin, twice daily 5 mg apixaban (odds ratio [OR] 0.79), twice daily 150 mg dabigatran (OR 0.65), once daily 60 mg edoxaban (0.86), and once daily 20 mg rivaroxaban reduced the risk of stroke or systemic embolism. However, once daily 60 mg edoxaban and once daily 20 mg rivaroxaban were associated with a higher risk for systemic embolism and stroke compared with twice daily 150 mg dabigatran (OR 1.33 and 1.35, respectively).

The risk for major bleeding was lower among patients receiving twice daily 5 mg apixaban (OR 0.71), twice daily 110 mg dabigatran (0.80), once daily 30 mg edoxaban (0.46), and once daily 60 mg edoxaban (0.78) compared with warfarin.

While most DOACs substantially lowered the risk for intracranial bleeding compared with warfarin, the risk for gastrointestinal bleeding was higher with some. In addition, all DOACs were associated with a lower risk for all-cause mortality compared with warfarin.

Overall, twice daily apixaban at 5 mg was ranked highest for most beneficial outcomes and was found to be more cost effective compared with warfarin.

“DOACs appear to be at least equivalent to warfarin at preventing stroke in patients with atrial fibrillation and to carry a reduced risk of bleeding,” the researchers concluded. “They overcome some of the limitations associated with warfarin and may lead to increased use by patients with atrial fibrillation.”

—Melissa Weiss

Reference:

López-López JA, Sterne JAC, Thom HHZ, et al. Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis BMJ [published online November 28, 2017]. BMJ. https://doi.org/10.1136/bmj.j5058.