DOACs as safe and effective as warfarin for patients with atrial fibrillation

October 30, 2018 – A new systematic review updates previous reviews comparing DOACs with warfarin.

Patients with atrial fibrillation are at increased risk for embolic stroke, heart failure, and cognitive impairment. Oral anticoagulation with vitamin K antagonists, such as warfarin, have been a standard for stroke prevention but are difficult to monitor and are associated with adverse food and drug interactions. Direct-acting oral anticoagulants (DOACs), such as dabigatran and apixaban, rivaroxaban, and edoxaban, are approved to treat atrial fibrillation, but it is unclear if they are as effective or safe as warfarin for preventing stroke.

Researchers from the DCRI led by Co-Chief Fellow Angela Lowenstern, MD, reviewed 117 published studies to compare DOACs with warfarin in preventing thromboembolic events and bleeding complications. Their review appears in the current issue of the Annals of Internal Medicine.

They found that the four available DOACs are at least as effective and safe as warfarin for patients with nonvalvular AF. Dabigatran is superior to warfarin in preventing stroke or systemic embolism. Apixaban is also superior to warfarin in preventing stroke or systemic embolism, and also has less risk for major bleeding. These findings provide evidence for the safety and efficacy of DOACs in treatment of patients. The medications also had similar benefits across several patient subgroups and seemed safe and efficacious for a wide range of patients with nonvalvular atrial fibrillation.

Further randomized clinical trials are needed to directly compare oral anticoagulants, including thrombin inhibitors and individual Xa inhibitors, the researchers noted.

In addition to Lowenstern, the study’s authors include Sana M. Al-Khatib, MD, MHS; Lauren Sharan, MD; Ranee Chatterjee, MD, MPH; Nancy M. Allen LaPointe, PharmD, MHS; Bimal Shah, MD, MBA; Ethan D. Borre, BA; Giselle Raitz, MD; Adam Goode, DPT, PhD; Roshini Yapa, MBBS; J. Kelly Davis, BA; Kathryn Lallinger, MSLS; Robyn Schmidt, BA; Andrzej S. Kosinski, PhD; Gillian D. Sanders, PhD.