Apixaban safer than rivaroxaban, warfarin for AF patients with cirrhosis

Patients with cirrhosis and nonvalvular atrial fibrillation (AF) who initiated rivaroxaban are more likely to experience major haemorrhage than those administered with apixaban, according to a study. However, the rates of ischaemic events and death are similar between the two treatment groups.

In addition, warfarin initiation is also associated with a higher rate of major haemorrhagic events, including stroke, relative to apixaban.

This population-based cohort study utilized two US claims datasets (ie, Medicare and Optum’s Clinformatics Data Mart Database [from 2013‒2022]). Patients with cirrhosis and nonvalvular AF initiating use of apixaban, rivaroxaban, or warfarin were matched 1:1 via propensity score (PS).

The researchers measured database-specific and pooled PS-matched rate differences (RDs) per 1,000 person-years (PY) and Cox proportional hazard ratios (HRs), controlling for 104 pre-exposure covariates. Ischaemic stroke or systemic embolism and major haemorrhage (ie, intracranial haemorrhage or major gastrointestinal bleeding) were the primary outcomes.

Rivaroxaban initiators showed significantly greater rates of major haemorrhagic events than apixaban initiators (RD, 33.1 per 1,000 PY, 95 percent confidence interval [CI], 12.9‒53.2; HR, 1.47, 95 percent CI, 1.11‒1.94). No significant differences were seen in the rates of ischaemic events or death between rivaroxaban and apixaban users.

In addition, subgroup and sensitivity analyses revealed consistently higher rates of major haemorrhage with rivaroxaban.

Similarly, warfarin initiators experienced significantly higher rates of major haemorrhage than apixaban initiators (RD, 26.1 per 1,000 PY, 95 percent CI, 6.8‒45.3; HR, 1.38, 95 percent CI, 1.03‒1.84), particularly haemorrhagic stroke (RD, 9.7 per 1,000 PY, 95 percent CI, 2.2‒17.2; HR, 2.85, 95 percent CI, 1.24‒6.59).

The study was limited by its nonrandomized treatment selection.