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Don Lavoie is alcohol programme manager at Public Health England and Gul Root is lead pharmacist, Health and Wellbeing Directorate, Public Health England
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a finger prick imageJuly 11 2018

Direct oral anticoagulants (DOACs) have been associated with reduced risks of major bleeding compared with the older anti-clotting drug, warfarin. 

Researchers at the University of Nottingham have found apixaban “to be the safest drug, with reduced risks of major, intracranial, and gastrointestinal bleeding compared with warfarin. Rivaroxaban and low dose apixaban were, however, associated with increased risks of all-cause mortality compared with warfarin.”

The observational study looked at patient records from 132 231 warfarin, 7744 dabigatran, 37 863 rivaroxaban, and 18 223 apixaban users. It divided the data into whether atrial fibrillation was present or not, and looked at the risks of bleeding, ischaemic stroke, venous thromboembolism, and all-cause mortality. 

In patients with atrial fibrillation, compared with warfarin:

  • apixaban was associated with a decreased risk of major bleeding (adjusted hazard ratio 0.66) and intracranial bleeding (0.40);
  • dabigatran was associated with a decreased risk of intracranial bleeding (0.45);
  • an increased risk of all-cause mortality was associated with rivaroxaban (1.19) or on lower doses of apixaban (1.27).

In patients without atrial fibrillation, compared with warfarin:

  • apixaban was associated with a decreased risk of major bleeding (0.60), any gastrointestinal bleeding (0.55), and upper GI bleeding (0.55);
  • rivaroxaban was associated with a decreased risk of intracranial bleeding (0.54);
  • an increased risk of all-cause mortality was observed with rivaroxaban (1.51) and lower doses of apixaban (1.34).

“The findings, published in the BMJ, provide initial reassurance about the safety of DOACs as an alternative to warfarin for all new patients,” said the University.

“For many years, warfarin has been the main treatment for potentially fatal blood clots, known as venous thromboembolism (VTE). But DOACs are increasingly being used as an alternative to warfarin because patients don’t need regular tests to check if they have the right amount of drug in their bloodstream.”

Links:
University of Nottingham announcement          
Y Vinogradova et al. ‘Risks and benefits of direct oral anticoagulants versus warfarin in a real world setting: cohort study in primary care’. BMJ 2018;362:k2505           

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