A multinational cohort study of persons with atrial fibrillation (AF) found that compared with all direct oral anticoagulants (DOACs), apixaban was associated with lower rates of gastrointestinal (GI) bleeding but similar rates of ischemic stroke, intracranial hemorrhage (ICH), and all-cause mortality. The findings are published in Annals of Internal Medicine.
DOACs are commonly used to prevent strokes in persons with AF. However, there is not clear guidance for choosing among the four available DOACs because head-to head clinical trial data are not available.

Researchers from University College London studied more than 500,000 new DOAC users in France, Germany, the United Kingdom, and the United States to compare outcomes and adverse effects. They analyzed data for 281,320 apixaban users; 61,008 dabigatran users; 12,722 edoxaban users; and 172,176 rivaroxaban users. They found that use of apixaban was associated with lower rates of GI bleeding compared to other DOACs.
However, no meaningful differences were observed between DOACs in outcomes or other comparisons. They report that users of apixaban experienced similar rates of ischemic stroke or systemic embolism, ICH, and all-cause mortality compared with other DOACs.
The authors also report that these findings were generally consistent for patients aged 80 years or older and patients with chronic kidney disease, who are often underrepresented in clinical trials. According to the authors, their results indicate that apixaban might be preferable to other DOACs because of the lower rate of GIB and similar rates of stroke and ICH, but consideration of all potential risks and benefits would be needed, such as the use of gastroprotective agents in patients with high risk for GIB.
Reference: Wallis C.Y. Lau, Carmen Olga Torre, Kenneth K.C. Man, Henry Morgan Stewart, Sarah Seager, Mui Van Zandt, Christian Reich, Jing Li, Jack Brewster, Gregory Y.H. Lip, Aroon D. Hingorani, Li Wei and Ian C.K. Wong https://doi.org/10.7326/M22-0511