Apixaban ranks highest for stroke prevention in atrial fibrillation

Reuters Health Information: Apixaban ranks highest for stroke prevention in atrial fibrillation

Apixaban ranks highest for stroke prevention in atrial fibrillation

Last Updated: 2017-12-11

By Reuters Staff

NEW YORK (Reuters Health) - Apixaban ranks higher than other direct-acting oral anticoagulants (DOACs) for preventing stroke in patients with atrial fibrillation (AF), according to a network meta-analysis.

DOACs offer important benefits over warfarin for preventing stroke in patients with AF, but it remains unclear how individual DOACs compare with one another and with warfarin in terms of safety, efficacy, and cost-effectiveness.

Dr. Jonathan A.C. Sterne from Bristol Medical School, University of Bristol, UK, and colleagues analyzed data from 23 randomized trials involving close to 95,000 patients to compare apixaban (Eliquis), edoxaban (Savaysa), rivaroxaban (Xarelto), and dabigatran (Pradaxa) with one another and with warfarin for stroke prevention in patients with AF. Their findings were published online November 28 in The BMJ.

Apixaban 5 mg twice daily ranked most effective for several outcomes, including stroke or systemic embolism, myocardial infarction, and all-cause mortality - and ranked safest among the compared medications, with the lowest incidence of major and gastrointestinal bleeding.

Edoxaban 60 mg once daily ranked second in effectiveness for major bleeding and all-cause mortality.

Rivaroxaban 20 mg once daily was the least effective of the DOACs for all outcomes except all-cause mortality.

For a 70-year-old patient starting anticoagulation, the estimated lifetime total cost of treatment was lowest for dabigatran 150 mg twice daily, followed by apixaban 5 mg twice daily, edoxaban 60 mg once daily, warfarin, and finally rivaroxaban 20 mg once daily.

For expected quality-adjusted life years (QALYs), apixaban ranked highest, followed by rivaroxaban, dabigatran, edoxaban, and warfarin.

In terms of cost-effectiveness, apixaban was the only DOAC for which the 95% confidence interval around incremental net benefit was positive, suggesting that it is more cost-effective than warfarin at a UK National Health Service willingness-to-pay level of 20,000 (US$26,857) per QALY.

The other DOACs would have to be sold at negative annual prices in order to become more cost-effective than apixaban, the researchers note.

"Despite a similar mechanism of action, apixaban at the right dose appears to maximize efficacy and safety among the DOACs, with favorable cost-effectiveness," they conclude. "Further long-term data may bring other insights with respect to safety, and it is important to identify patient groups that may not benefit from DOACs, as well as to develop drugs to reverse the anticoagulant effects of each DOAC."

"Additional investments in new trials that address limitations of the current evidence may help practitioners and policy makers better understand the role of DOACs in this clinical setting," the authors add.

Dr. Sterne did not respond to a request for comment.

SOURCE: http://bit.ly/2BiVtQn

BMJ 2017.

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