What is the comparison between Apixaban, Rivaroxaban, and Dabigatran?

From the Guidelines

Apixaban, Rivaroxaban, and Dabigatran are all effective alternatives to warfarin for stroke prevention in nonvalvular atrial fibrillation, with Apixaban showing superior efficacy and safety profiles in some studies.

Comparison of Efficacy and Safety

• Efficacy: All three medications have been shown to be at least as effective as warfarin in preventing stroke and systemic embolism in patients with nonvalvular atrial fibrillation 1.
• Safety: Apixaban has been associated with lower rates of major bleeding and intracerebral hemorrhage compared to warfarin, while Rivaroxaban and Dabigatran have shown similar or slightly higher rates of major bleeding 1.

Key Findings

• The ARISTOTLE trial found that Apixaban was superior to warfarin in reducing stroke or systemic embolism (1.27% vs 1.60%) and major bleeding (2.13% vs 3.09%) 1.
• The ROCKET AF trial found that Rivaroxaban was noninferior to warfarin in reducing stroke or systemic embolism (2.1% vs 2.4%) and major bleeding (5.6% vs 5.4%) 1.
• The RE-LY trial found that high-dose Dabigatran was associated with lower stroke rates (1.11% vs 1.69%) and similar bleeding rates compared to warfarin 1.

Clinical Considerations

• When choosing between Apixaban, Rivaroxaban, and Dabigatran, clinicians should consider individual patient factors, such as renal function, age, and weight, as well as the potential for drug interactions and the need for monitoring 1.
• Apixaban may be a preferred option for patients with nonvalvular atrial fibrillation who are deemed unsuitable for vitamin K antagonist therapy or have a high risk of bleeding 1.
• Rivaroxaban and Dabigatran should not be used in patients with severe renal impairment (CrCl <15 mL/min) 1.

From the Research

Comparison of Apixaban, Rivaroxaban, and Dabigatran

• The studies 2, 3, 4, 5, 6 compared the effectiveness and safety of apixaban, rivaroxaban, and dabigatran in patients with non-valvular atrial fibrillation.
• In terms of effectiveness, the studies found that:
  • Apixaban, rivaroxaban, and dabigatran had similar effectiveness in preventing ischemic stroke, transient ischemic attack, or systemic embolism 2, 3, 5.
  • Dabigatran 150 mg bid may be more effective than rivaroxaban in preventing ischemic stroke or systemic embolism 4, 6.
• In terms of safety, the studies found that:
  • Apixaban was associated with a lower risk of major bleeding compared to dabigatran and rivaroxaban 3, 4, 5, 6.
  • Rivaroxaban was associated with an increased risk of major bleeding and intracranial bleeding compared to dabigatran 3, 5.
  • Dabigatran and apixaban had a lower risk of gastrointestinal bleeding compared to rivaroxaban 2, 5.

Efficacy and Safety Outcomes

• The studies reported the following efficacy and safety outcomes:
  • Ischemic stroke or systemic embolism: apixaban, rivaroxaban, and dabigatran had similar effectiveness 2, 3, 5.
  • Major bleeding: apixaban had a lower risk compared to dabigatran and rivaroxaban 3, 4, 5, 6.
  • Intracranial bleeding: rivaroxaban had a higher risk compared to dabigatran and apixaban 3, 6.
  • Gastrointestinal bleeding: dabigatran and apixaban had a lower risk compared to rivaroxaban 2, 5.

Study Limitations

• The studies had limitations, including:
  • Indirect comparisons between the three drugs 6.
  • Differences in patient populations and study designs 2, 3, 4, 5.
  • Limited follow-up periods 2, 3, 5.