Is apixaban safer and more effective than rivaroxaban?

New research suggests that for individuals with atrial fibrillation, the blood-thinning drug apixaban may be safer and more effective at preventing strokes and systemic blood clots compared with rivaroxaban.

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A team of researchers from Brigham and Women's Hospital, Harvard Medical School (both MA, USA), Sinai Health System and the University of Toronto (both ON, Canada), has evaluated the comparative safety and effectiveness of apixaban versus rivaroxaban for the prevention of stroke and/or systemic blood clotting in individuals with atrial fibrillation. The results of the large cohort study suggest apixaban may exhibit superior safety and effectiveness over rivaroxaban.

Individuals with atrial fibrillation can be routinely prescribed anticoagulant, blood-thinning drugs – such as warfarin – for the prevention of blood clot formation or stroke incidence. Both apixaban and rivaroxaban are newer such therapies, which display superior safety compared with warfarin. Apixaban and rivaroxaban now represent the most commonly prescribed, direct oral anticoagulants for adults with atrial fibrillation, however, to date, few studies have evaluated the direct comparative effectiveness of these two newer therapies against each other.

In this study, researchers analyzed and compared data on close to 80,000 individuals with atrial fibrillation, from a nationwide US commercial insurance claims database, who were newly prescribed either apixaban or rivaroxaban. Investigators employed propensity-score matching to compare the outcomes of 39,351 eligible study participants who were prescribed apixaban with 39,351 individuals who were prescribed rivaroxaban.

In assessing the comparative effectiveness of the two drugs, investigators defined the primary effectiveness outcome as a composite of ischemic stroke or systemic embolism incidence; the primary safety outcome was defined by a composite of intracranial or gastrointestinal hemorrhage.

After a mean 9-month follow-up period, researchers observed reduced rates of stroke, systemic blood clotting, and brain or gastrointestinal bleeding amongst individuals who received first-line apixaban compared with those who were prescribed rivaroxaban.

In the study, the authors concluded: “In routine care, adults with atrial fibrillation prescribed apixaban had a lower rate of both ischemic stroke or systemic embolism and bleeding compared with those prescribed rivaroxaban.”

The authors express that the results of their study could be important for helping to inform decision making when discussing treatment options with individuals with atrial fibrillation.


Fralick M, Colacci M, Schneeweiss S, Huybrechts KF, Lin KJ, Gagne JJ. Effectiveness and safety of apixaban compared with rivaroxaban for patients with atrial fibrillation in routine practice: a cohort study. Ann Intern Med. doi:10.7326/M19-2522 (2020) (Epub ahead of print).

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Ilana Landau

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