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Apixaban or Rivaroxaban – Which Is Best for VTE?

February 21, 2022

Written by Denrick Cooper

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Apixaban and rivaroxaban are two of the most prescribed direct oral anticoagulants (DOACs), but there are limited head-to-head comparisons of the medications. This study finds apixaban is associated with lower rates of VTE recurrence, GI  bleeds and ICH compared to rivaroxaban.

Why does this matter?
We recently covered an update on antithrombotic therapy for (venous thromboembolism) VTE suggesting DOACs be used as first line agents in particular instances. With no direct head-to-head RCTs, prior research focuses on smaller observational trials and data when apixaban was initially released in 2015. This large observational study adds more information to the effectiveness and risk profiles of the two.

Imma let you finish rivaroxaban, but apixaban is the greatest of all time!
This study is a large retrospective cohort trial comparing apixaban and rivaroxaban. Patients were taken from a privately insured database and included if one prescription of either was given between January 2015 and  June 2020. Patients were studied if they were diagnosed with VTE on an inpatient encounter and started on a DOAC within 30 days. Based on 1:1 propensity score matching, apixaban users had a lower risk of VTE recurrence compared to rivaroxaban users (8.9 vs 11.4 events per 100 person-years). Apixaban also had lower rates of ICH and GI bleeds (7.2 vs 11.0 per 100 person-years).

This study is a step forward in elucidating the effectiveness and safety of two of the most commonly prescribed DOACs. The results fall in line with previous meta-analyses. From the ED perspective, it would’ve been helpful to include patients from the outpatient setting. Also, the data set is from commercially insured patients which, for many EDs, does not reflect our patient population. Currently, unless other underlying factors are at play, apixaban seems to be the more effective, safer option for the treatment of VTE.

Risk for Recurrent Venous Thromboembolism and Bleeding With Apixaban Compared With Rivaroxaban: An Analysis of Real-World Data. Ann Intern Med. 2022 Jan;175(1):20-28. doi: 10.7326/M21-0717. Epub 2021 Dec 7.

What are your thoughts?