Direct-acting oral anticoagulants (DOACs) are superior to warfarin for stroke prevention in atrial fibrillation (AF), according to a new review. Of the DOACs, apixaban may be the best of the bunch. The DOACs, which include edoxaban, rivaroxaban, apixaban, and dabigatran, were compared to warfarin regarding efficacy, safety, and cost effectiveness in patients with AF. Researchers studied 23 randomized trials that included some 95,000 patients in a “network meta-analysis” in which 13 studies compared a DOAC to warfarin. All DOACs were superior to warfarin in reducing stroke or systemic embolism. The risk of all-cause mortality was lower with DOACs than warfarin as was the risk of major bleeding. The risk of intracranial bleeding also was lower with DOACs compared to warfarin, but the risk of gastrointestinal bleeding was lower with warfarin. Apixaban 5 mg twice daily was ranked highest for almost all outcomes and was favorably cost effective compared to warfarin. The authors acknowledged that this was an indirect comparison and that direct comparisons are needed (BMJ 2017 Nov 28;359:j5058. doi: 10.1136/bmj.j5058).
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