Comparative Effectiveness and Safety of Apixaban, Rivaroxaban, and Warfarin in Patients with Cirrhosis and AF
Clinical question: What is the effectiveness and safety of apixaban, rivaroxaban, and warfarin in patients with cirrhosis and atrial fibrillation?
Background: The use of direct oral anticoagulants for atrial fibrillation (AF) has increased rapidly, including in patients with cirrhosis. To date, no large study of patients with both cirrhosis and AF has directly compared apixaban, rivaroxaban, and warfarin in a head-to-head manner. Understanding differences in the safety and effectiveness of these agents in cirrhosis could have major implications for clinical care.
Study design: Population-based cohort study
Setting: Two U.S. claims data sets (Medicare and Optum’s de-identified Clinformatics Data Mart Database [2013 to 2022])
Synopsis: Researchers examined a total of 24,138 propensity score-matched patients with cirrhosis and nonvalvular AF who were initiated on apixaban, rivaroxaban, and warfarin. This study demonstrated that patients initiated on rivaroxaban had significantly higher rates of major hemorrhagic events compared to apixaban initiators, with an absolute risk difference of 33.1 per 1,000 person-years (PY) (95% confidence interval [CI], 12.9 to 53.2 per 1,000 PY, hazard ratio, 1.47 [CI, 1.11 to 1.94]), but no significant differences in rates of ischemic events or death. Warfarin initiators also had significantly higher rates of major hemorrhage than apixaban initiators, with an absolute risk difference of 26.1 per 1,000 PY (CI, 6.8 to 45.3 per 1,000 PY, hazard ratio 1.38 [CI, 1.03 to 1.84]), particularly hemorrhagic stroke. The main limitation of this study is the nonrandomized treatment selection. Given warfarin use is challenging in advanced liver disease because of the accompanying coagulopathy, as well as the superior safety profile demonstrated in the apixaban group, this study assists hospitalists in anticoagulation agent choice in this patient population.
Bottom line: Apixaban may offer safety benefits over both rivaroxaban and warfarin in patients with cirrhosis and AF.
Citation: Simon TG, et al. Comparative effectiveness and safety of apixaban, rivaroxaban, and warfarin in patients with cirrhosis and atrial fibrillation: a nationwide cohort study. Ann Intern Med. 2024;177(8):1028-1038. doi: 10.7326/M23-3067.
Dr. Arnon is an academic hospitalist in the section of hospital medicine at UPMC Presbyterian Hospital, and a clinical assistant professor of medicine at the University of Pittsburgh School of Medicine, both in Pittsburgh.