Blood thinners: Apixaban has the lowest risk of gastrointestinal bleeding compared to other direct oral anticoagulants

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A large-scale comparison of direct oral anticoagulants (blood thinners), commonly prescribed for an irregular heartbeat, identified the drug with the lowest bleeding risk, in a new study led by University of California researchers.

In the paper published in Annals of internal medicineOne of the most common direct oral anticoagulants (DOACs), apixaban, has the lowest risk of gastrointestinal bleeding, with similar performance in preventing stroke and other side effects, researchers report.

DOACs are used to prevent strokes in people with atrial fibrillation — a slow or irregular heartbeat — a condition that affects more than 33 million people worldwide. It has recently become more popular than warfarin, the previous standard treatment, because it does not require as much monitoring for follow-up (which has been particularly valuable during the Covid-19 pandemic) and has a lower risk of side effects.

For the new study, researchers compared the effectiveness and risk of side effects for four of the most common DOACs. They reviewed data from more than 500,000 new users of DOAC in the United Kingdom, France, Germany and the United States, including 281,320 Apixaban users, 61,008 dabigatran users, 12,722 edoxaban users, and 172,176 rivaroxaban users.

They found that all four drugs were comparable in terms of stroke outcomes, brain hemorrhage, and all-cause mortality, while they identified a difference in the risk of gastrointestinal bleeding, one of the most common and worrisome side effects of DOACs.

The study revealed that apixaban emerged as having a lower risk of gastrointestinal bleeding, with a 19-28% lower risk when compared directly to each of the other three.

The researchers found that their findings held true when looking at data only from those over 80, and those with chronic kidney disease, two groups that are often underrepresented in clinical trials.

Co-lead author Dr. Wallis Lau (UCLA School of Pharmacy) said: “Direct oral anticoagulants have been prescribed with increasing frequency worldwide in recent years, but evidence comparing them directly has been limited. Our results suggest that apixaban may be Preferred over other blood thinners due to the lower rate of GI bleeding and similar rates of stroke, a finding that we hope will be supported by randomized controlled trials.

“As with all medications, potential risks and benefits can vary between people, so consideration of the full range of outcomes and side effects will still be necessary for each individual patient.”

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