A nationwide cohort study found that among patients with cirrhosis and nonvalvular atrial fibrillation (AF), initiating treatment with anticoagulant therapy, apixaban, may offer a safety benefit compared with rivaroxaban or warfarin. These findings are important because AF affects more than 15% of patients with cirrhosis and many of them are prescribed a DOAC (direct oral anticoagulant), such as apixaban or rivaroxaban. However, no large studies focused on cirrhosis and AF have directly compared the two DOACs and warfarin. The study is published in Annals of Internal Medicine.

Researchers from Brigham and Women's Hospital, Harvard Medical School studied data from two U.S. claims data sets to compare the effectiveness and safety of apixaban versus rivaroxaban and versus warfarin in patients with cirrhosis and AF. Patient data was assessed for ischemic stroke or systemic embolism and major hemorrhage (intracranial hemorrhage or major gastrointestinal bleeding). The data showed that patients initiating rivaroxaban treatment had significantly higher rates of major hemorrhagic events than those initiating treatment with apixaban. Specifically, rivaroxaban initiators had 47% higher rates of major hemorrhagic events compared with apixaban initiators.

Similarly, warfarin initiators had 38% higher rates of major hemorrhage compared with apixaban initiators, including a 2.9-fold higher rate of hemorrhagic stroke. The incidence of ischemic events was similar among all groups. According to the authors, these findings suggest apixaban may offer greater relative safety benefits, and this could help guide clinical care for a patient population that has lacked sufficient data to inform treatment selection.

Reference:

Tracey G. Simon, Daniel E. Singer, Yichi Zhang, Julianna M. Mastrorilli, BS, Alexander Cervone, Comparative Effectiveness and Safety of Apixaban, Rivaroxaban, and Warfarin in Patients With Cirrhosis and Atrial Fibrillation: A Nationwide Cohort Study, Annals of Internal Medicine, https://doi.org/10.7326/M23-3067