From the Guidelines
Apixaban is the most effective Direct Oral Anticoagulant (DOAC) for most patients with atrial fibrillation or venous thromboembolism, due to its favorable bleeding risk profile and twice-daily dosing 1. When considering the most effective DOAC, several factors come into play, including the patient's renal function, concomitant medications, compliance concerns, cost, and bleeding risk.
- Apixaban (Eliquis) is often preferred due to its favorable bleeding risk profile and twice-daily dosing (5mg twice daily typically, with dose reduction to 2.5mg twice daily for certain patients) 1.
- Rivaroxaban (Xarelto) offers convenient once-daily dosing (20mg daily with food for atrial fibrillation; 15mg twice daily for 21 days followed by 20mg daily for VTE) 1.
- Dabigatran (Pradaxa) has the advantage of having a reversal agent (idarucizumab) and is dosed 150mg twice daily for most patients 1.
- Edoxaban (Savaysa) is another once-daily option (60mg daily, with dose reduction to 30mg for certain patients) 1. The choice between these medications should consider individual patient factors, and all DOACs have better safety profiles than warfarin with less intracranial hemorrhage risk and no need for routine monitoring, though regular assessment of renal function remains important for appropriate dosing 1. Meta-analyses of individual data from 71,683 RCT patients showed that standard, full-dose DOAC treatment compared with warfarin reduces the risk of stroke or systemic embolism, all-cause mortality, and intracranial bleeding 1. Post-marketing observational data on the effectiveness and safety of dabigatran, rivaroxaban, apixaban, and edoxaban vs. warfarin show general consistency with the respective phase 3 RCTs 1. Ultimately, apixaban is the preferred choice due to its overall favorable profile, as evidenced by the most recent and highest quality study 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Effectiveness of Direct Oral Anticoagulants (DOACs)
- The study 2 found that apixaban use was associated with lower risk for gastrointestinal bleeding (GIB) than use of dabigatran, edoxaban, or rivaroxaban.
- Another study 3 found that apixaban was the best among DOACs in preventing stroke or systemic embolism, and also had the lowest risk of major bleeding.
- A network meta-analysis 3 ranked apixaban as the best in efficacy and safety, followed by rivaroxaban, edoxaban, dabigatran, and warfarin.
Safety of DOACs
- The study 4 found that patients treated with standard dose apixaban or dabigatran had lower risk of major bleeding than patients treated with rivaroxaban.
- Another study 5 found that DOACs (apixaban, dabigatran, or rivaroxaban) may be well-tolerated and effective anticoagulant options in patients with nonvalvular atrial fibrillation weighing ≥ 120 kg.
- A cohort study 6 found that apixaban showed lower risk of major bleeding and gastrointestinal bleeding versus rivaroxaban in all subgroups evaluated, and versus dabigatran in elderly patients, patients with HAS-BLED score ≥3, and those receiving concomitant medications.
Comparison of DOACs
- The study 2 found that apixaban use was associated with similar rates of ischemic stroke or systemic embolism, intracranial hemorrhage, and all-cause mortality compared with dabigatran, edoxaban, and rivaroxaban.
- Another study 4 found that no differences in effectiveness were found between apixaban, dabigatran, and rivaroxaban.
- A cohort study 6 found that DOACs (apixaban, rivaroxaban, and dabigatran) were associated with improved safety and effectiveness when compared to vitamin K antagonists (VKAs) among subgroups of non-valvular atrial fibrillation patients at high risk of gastrointestinal bleeding.