Effectiveness and safety of apixaban and rivaroxaban vs warfarin in patients with atrial fibrillation and chronic kidney disease

Effectiveness and Safety of Dose-Specific DOACs in Patients With Atrial Fibrillation: A Systematic Review and Network Meta-Analysis

Background: Dose adjustments of direct-acting oral anticoagulants (DOACs) for atrial fibrillation are based on pivotal clinical trials assessing their effectiveness and safety in controlled settings. However, the appropriateness of these dosing strategies in real-world practice is uncertain. The purpose of this study is to compare the effectiveness and safety of dose-specific DOACs with those of warfarin. Methods: This study retrieved articles from MEDLINE, Embase, and CENTRAL until March 5, 2024. Primary outcomes were the incidence of stroke/systemic embolisms (S/SEs) and major bleeding (MB). Direct pairwise meta-analyses compared each dose-specific DOAC with warfarin. Heterogeneity was assessed using Higgin's I 2 and Q statistics, while publication bias was evaluated through funnel plots and Begg's and Egger's tests, with adjusted pooled estimates calculated via trim-and-fill and precision-effect estimate with standard error (PET-PEESE) methods. A network analysis was conducted, with additional comparisons made using a Bayesian random-effects model for indirect evidence. Results: A total of 32 studies with 2,332,770 patients were included. Both standard-dose (SD) and low-dose (LD) DOACs significantly reduced S/SE, except for LD apixaban and LD edoxaban. Rivaroxaban did not show significant difference in MB compared to warfarin. In East Asian patients, all doses of DOACs exhibited lower hazard ratios (HRs) for S/SE and MB than those observed in the primary analysis, with LD rivaroxaban significantly reducing MB, a finding not observed in the primary analysis. Rank probability analysis indicated that the dose-specific DOACs had different safety profiles and small but meaningful differences in effectiveness. SD apixaban (S/SE: second, MB: second) and edoxaban (S/SE: first, MB: fourth) and LD edoxaban (S/SE: fourth, MB: first) had high ranks. LD apixaban had the most significant difference in rank for S/SE from SD apixaban, ranking eighth compared to second. Conclusions: This study found that all DOACs provided comparable or superior effectiveness and safety to warfarin. SD apixaban, SD edoxaban, and LD edoxaban achieved a favorable balance between preventing S/SE and MB risk.

Prophylactic direct oral anticoagulants vs. low molecular weight heparin after urological surgery: A systematic review and meta-analysis

Purpose

To compare the outcomes of using prophylactic direct oral anti-coagulants (DOAC) and low-molecular-weight heparin (LMWH) after major urologic surgery.

Materials and Methods

Systematic literature searches of MEDLINE, Embase, Web of Science, and Cochrane CENTRAL were performed up to 9 November 2023, and protocols were registered on PROSPERO (CRD42024494424). The primary outcomes were post-operative incidence of VTE and bleeding. The secondary outcomes included re-admissions and transfusions needed, post-operative complications and exploring the radical cystectomy sub-group. Outcomes were reported in 30 and 90 days where feasible with sub-group analysis.

Results

Searches yielded four studies that included 856 patients and the outcomes were reported within 30 and 90 days, with sub-analysis performed for each time-interval. We found no statistically significant differences between DOAC and LWMH within neither primary nor secondary outcomes; VTE events (RR 0.36; p = 0.06); bleeding events (RR 0.64; p = 0.45); re-admissions (RR 1.14; p = 0.39); transfusions (RR 0.42; p = 0.05) within 0-90 days and post-operative complications within 30 days (RR 0.76; p = 0.17). Similar results were found when exploring radical cystectomy sub-group: VTE risk (RR 0.42, p = 0.15), bleeding risk (RR 1.09; p = 0.90), and re-admissions to hospital (RR 1.18, p = 0.35). Limitations include small sample size, and difficult generalization to all urological surgery as most of the analyzed cohort underwent radical cystectomy.

Conclusion

DOACs may be a safe and possibly cost-effective alternative to LMWH as post-operative thromboprophylaxis. However, these findings should be interpreted with caution due to limitations; therefore, more randomized studies are needed to ascertain our findings.