Comparative efficacy and safety of oral anticoagulants for the treatment of venous thromboembolism in the patients with different renal functions: a systematic review, pairwise and network meta-analysis

Abstract

ObjectivesTo compare the efficacy and safety of direct oral anticoagulants (DOACs) in patients with venous thromboembolism (VTE) and different renal functions.DesignSystematic review containing pairwise and Bayesian network meta-analysis of randomised controlled trials (RCTs).Data sourcesMEDLINE, EMBASE and Cochrane Library.Eligibility criteriaRCTs reporting the efficacy and safety outcomes of DOACs in different creatinine clearance (CrCl) subgroups.Data extraction and synthesisData extraction and quality assessment were undertaken by two independent reviewers. Data were pooled using the DerSimonian-Laird method in pairwise meta-analysis. Network meta-analysis within a Bayesian framework was conducted.ResultsData from 10 RCTs were included. In the treatment of acute VTE, DOACs did not significantly reduce recurrent VTE or VTE-related death (OR, 0.96; 95% CI, 0.82 to 1.11) but significantly reduced bleeding events (0.76, 0.68 to 0.90) compared with warfarin. In the extended treatment of VTE, DOACs produced significant benefits in recurrent VTE or VTE-related death (0.23, 0.16 to 0.29), but significantly increased bleeding events (1.86, 1.04 to 3.33) compared with placebo/aspirin. There were no significant differences in efficacy and safety of DOACs among the three CrCl stratified subgroups in acute and extended treatment of VTE (p for subgroup heterogeneity >0.1). Bayesian network meta-analysis suggested that apixaban 2.5 mg and 5 mg two times per day were associated with a lower risk of bleeding than dabigatran, rivaroxaban, warfarin and aspirin in the subgroup with CrCl >80 mL/min.ConclusionsFor the treatment of acute VTE, DOACs are similar to warfarin in reducing recurrent VTE and VTE-related death but are significantly superior to warfarin in reducing the risk of bleeding. For the efficacy and safety of DOACs across different CrCl stratifications (30–50, 50–80 and more than 80 mL/min), no significant difference was found. In light of minimal evidence, apixaban might be associated with a lower risk of bleeding in patients with VTE and CrCl >80 mL/min.PROSPERO registration numberCRD42018090896.

Pharmacological Thromboprophylaxis for VTE Post-Endovenous Ablation of Varicose Veins: Network Meta-Analysis

“…14 Therefore we feel it will remain a case per case basis whether or not someone should be prescribed anticoagulants post op. Interestingly, a number of medical reviews and NMA have shown that apixaban is associated with the lowest bleeding risk, 15,16 however there is only one randomized trial that utilized apixaban as a strategy for reducing post operative VTE, unfortunately it was not compared with other anticoagulants which would of been very useful as part of our analysis. 17 Another important aspect of thromboprophylaxis post endovenous ablation is recanalization of the treated vein.…”

Safety and Effectiveness of Direct Xa Inhibitors vs Warfarin in Patients with Nephrotic Syndrome

“…Direct oral anticoagulant agents (DOACs) have been proved to have comparative efficacy and safety profiles as warfarin in reducing the risk of thromboembolic stroke and they are currently widely used in many patient groups. DOACs have been shown to be non-inferior to warfarin in mild to moderate CKD 7 .…”

The Safety of Direct Oral Anticoagulants Versus Warfarin Among Older Individuals With Acute Venous Thromboembolism and CKD: A Population-Based Cohort Study

“…Data from randomized controlled trials of acute VTE treatment with oral anticoagulants have demonstrated very low rates of major bleeding events among individuals with and without CKD. 2 , 6 , 7 , 8 However, because randomized controlled trials tend to include select populations that are closely monitored, they may underreport important safety outcomes compared to what is seen in “real world” practice. Reassuringly, our data on major bleeding is concordant with that reported in seminal randomized controlled trials and some observational studies.…”