Comparative Effectiveness of Dabigatran, Rivaroxaban, Apixaban, and Warfarin in the Management of Patients With Nonvalvular Atrial Fibrillation

Alternative anticoagulants to warfarin (dabigatran, rivaroxaban, and apixaban) are becoming available for the prevention of thromboembolic stroke in atrial fibrillation (AF), but there is a lack of information on their comparative effectiveness. Using a discrete event simulation method adopting a lifetime horizon of analysis, we made an indirect comparison of the RE-LY, ROCKET-AF, and ARISTOTLE trial results for AF patients in the US population. Over a lifetime, apixaban, dabigatran, and rivaroxaban accrued 0.130 (95% central range (CR) −0.030 to 0.264), 0.106 (95% CR −0.048 to 0.248), and 0.095 (95% CR −0.052 to 0.242) more quality-adjusted life-years (QALYs), respectively, than warfarin, with apixaban having a 55% probability of accruing the highest total QALYs. In the absence of a definitive trial, and acknowledging the limitations of an indirect comparison, the available evidence suggests apixaban to be the most effective anticoagulant.