Physicians' Academy for Cardiovascular Education

Direct oral anticoagulants have different gastrointestinal safety profiles

Gastrointestinal Safety of Direct Oral Anticoagulants: A Large Population-Based Study

Literature - Abraham NS, Noseworthy PA, Yao X, et al. - Gastroenterology 2017;152:1014–1022


When physicians prescribe anticoagulants, they prefer direct oral anticoagulants (DOACs) in approximately 62% of new cases, because they are at least equivalent to warfarin for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF), and easier to use since there is no need for monitoring [1,2]. Compared with warfarin, there is a 25–30% increased risk of gastrointestinal (GI) bleeding with DOACs, however, the comparative risk of GI bleeding between them is not known [3-6].

In this analysis of a population-based cohort, the GI safety profile of DOACs was assessed in a head-to-head comparison, with focus on the very elderly (≥75 years). In total, 6 542 patients with AF were included in the apixaban vs dabigatran cohort, 6 565 AF patients in the apixaban vs rivaroxaban cohort and 15 787 AF patients in the rivaroxaban vs dabigatran cohort.

Main results

Risk of GI bleeding with rivaroxaban vs dabigatran:

Risk of GI bleeding with apixaban vs dabigatran:

Risk of GI bleeding with apixaban vs rivaroxaban:

Apixaban had the most favourable GI safety profile compared with rivaroxaban (ARR= -2.20; 95% CI: -3.00 to -1.40; NNH = 45) and dabigatran (ARR = -1.35; 95% CI: -2.03 to -0.67; NNH = 74).


In a large population-based cohort of patients on DOACs due to non-valvular AF, apixaban had the most favourable GI safety profile among all age groups and rivaroxaban had the least favourable profile. These results may facilitate clinical decision making, when it comes to the selection of a DOAC for AF patients.


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