Quick Takes

  • More than 36,000 patients with VTE newly starting apixaban or rivaroxaban were compared and followed for >3 months using medical claims.
  • Use of apixaban was associated with a lower risk of intracranial or gastrointestinal bleeding as compared to rivaroxaban therapy.
  • Use of apixaban was associated with a lower risk of recurrent VTE as compared to rivaroxaban therapy.

Study Questions:

What is the effectiveness and safety of apixaban as compared to rivaroxaban for treatment in patients with venous thromboembolism (VTE)?


The authors conducted a retrospective new-user cohort study from a United States-based commercial health care insurance database between January 2015 and June 2020. Patients with VTE who were newly prescribed apixaban or rivaroxaban were identified. The primary effectiveness outcome was recurrent VTE, including both pulmonary embolism and deep vein thrombosis. The primary safety outcome was a composite of gastrointestinal and intracranial bleeding. Propensity score matching was used to reduce differences in baseline characteristics between the two treatment cohorts.


After propensity matching, the study included 18,618 patients in each treatment cohort with a median follow-up of 102 days (interquartile range [IQR], 30-128 days) for apixaban and 105 days (IQR, 30-140 days) for rivaroxaban. Patients treated with apixaban experienced a lower rate of recurrent VTE (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.68-0.87) as well as a lower rate of bleeding (HR, 0.60; 95% CI, 0.53-0.69) as compared to rivaroxaban.


The authors concluded that patients with VTE who newly started apixaban experienced lower rates of recurrent VTE and bleeding than patients newly starting rivaroxaban.


All four available direct oral anticoagulants (DOACs; apixaban, dabigatran, edoxaban, and rivaroxaban) have been shown in prospective randomized trials to be as effective and similarly safe or safer than warfarin therapy for acute treatment of VTE. However, there have been no large, prospective, randomized trials comparing one DOAC to another for treatment of acute VTE. This retrospective, insurance claims study adds to an existing body of literature comparing the two most commonly used DOACs in the United States: apixaban and rivaroxaban. As has been seen in other retrospective analyses, apixaban treatment is associated with a lower risk of gastrointestinal and intracranial hemorrhage as compared to rivaroxaban therapy. However, this study also suggests that apixaban therapy is associated with a lower risk of recurrent VTE as compared to rivaroxaban therapy. For many clinicians, these data support their decision to use apixaban as first-line therapy for treatment of acute VTE. However, it is important to remember that many patients may struggle to take apixaban twice daily for 3-6 months (or indefinitely). For those patients, rivaroxaban offers the advantage of being once daily after the initial 3 weeks of therapy.

Clinical Topics: Anticoagulation Management, Cardiovascular Care Team, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism

Keywords: Anticoagulants, Dabigatran, Gastrointestinal Hemorrhage, Intracranial Hemorrhages, Pulmonary Embolism, Rivaroxaban, Secondary Prevention, Vascular Diseases, Venous Thromboembolism, Venous Thrombosis

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