Apixaban (Eliquis): Lowering the Risk of Fatal Ischaemic and Haemorrhagic Events in Anticoagulation

With robust clinical trial and real-world data showing significant advantages over traditional agents like warfarin, direct oral anticoagulants (DOACs) have transformed anticoagulation therapy. Their efficacy and ease of use have made DOACs like rivaroxaban and apixaban (Eliquis) key therapeutic agents of anticoagulation.^1,2

The choice of anticoagulant therapy plays a critical role in preventing both thrombotic and bleeding complications and the different risk profiles of these drugs, particularly regarding ischemic and hemorrhagic events, remain to be a critical clinical consideration that have prompted comparative investigations.³

A notable study examined the relative safety of rivaroxaban and apixaban in the real world, involving 581,451 patients on US Medicare database who were 65 years or older and were given either apixaban or rivaroxaban. The patients were followed up for 4 years. The study looked at the composite of major ischemic and hemorrhagic events as primary outcome.³ This cohort study provided important insights into the key differences on the bleeding risk profiles of these medications.

The Study: What Was Found

One of the remarkable findings from this research is the significant difference in the risk of fatal events between patients treated with rivaroxaban and those on apixaban. Across various patient populations, including those with atrial fibrillation and venous thromboembolism, apixaban consistently demonstrated a reduced risk of fatal ischemic and hemorrhagic events. The results were striking; rivaroxaban was associated with a 34% increased risk of these fatal events (hazard ratio 1.34, 95% confidence interval 1.17–1.53).³ (See figure 1).



This difference could be attributed to apixaban’s pharmacokinetics, including a lower peak-to-trough concentration ratio compared to rivaroxaban, which could translate to less variability in anticoagulation effect and a reduced risk of over-anticoagulation. This elevated risk points to a higher likelihood of life-threatening complications with rivaroxaban, a consideration that should weigh heavily in clinical decision-making on which DOAC to use.³

Conclusion

The different risk profiles of rivaroxaban and apixaban are highly relevant in day-to-day clinical decision-making. Patients requiring anticoagulation often have complex risk factors, including advanced age, concomitant cardiovascular disease, and other comorbidities that predispose them to both thrombotic and bleeding events. Most of these patients will need long-term anticoagulation making a balance of the risks of stroke, thrombosis, and bleeding paramount. The importance of individualizing anticoagulant therapy based on a patient’s overall risk profile is critical. And in cases where the risk of fatal bleeding or ischemic events is a major concern, apixaban may offer a safer alternative that could lead to improved patient outcomes and reduced incidence of catastrophic complications associated with anticoagulation therapy.