Comparisons of effectiveness and safety between on-label dosing, off-label underdosing, and off-label overdosing in Asian and non-Asian atrial fibrillation patients treated with rivaroxaban: a systematic review and meta-analysis of observational studies

Abstract

Background and Aims Limited real-world data show that rivaroxaban following dosage criteria from either ROCKET AF (20mg/day or 15mg/day if creatinine clearance [CrCl]<50ml/min) or J-ROCKET AF (15mg/day or 10mg/day if CrCl<50ml/min) are associated with comparable risks of thromboembolism and bleeding with each other in patients with non-valvular atrial fibrillation (NVAF). We are aimed to study whether these observations differ between Asian and non-Asian subjects. Methods A systematic review and meta-analysis with random effects was conducted to estimate the aggregate hazard ratio (HR) and 95% confidence interval (CI) using PubMed and MEDLINE databases from September 8, 2011 to December 31, 2022 searched for adjusted observational studies that reported relevant clinical outcomes of NVAF patients receiving rivaroxaban 10mg/day if CrCl>50ml/min, on-label dose rivaroxaban eligible for ROCKET AF or J-ROCKET AF, and rivaroxaban 20mg/day if CrCl<50ml/min. Effectiveness and safety endpoints were compared between ROCKET AF and J-ROCKET AF dosing regimen in Asian and non-Asian subjects, separately. Also, risks of events of rivaroxaban 10mg/day despite of CrCl>50ml/min and rivaroxaban 20mg/day despite of CrCl<50ml/min were compared to that of “ROCKET AF/J-ROCKET AF dosing”. Sensitivity analyses were performed by sequential elimination of each study from the pool. The meta-regression analysis was performed to explore the influence of potential factors on the effectiveness and safety outcomes. Results Eighteen studies involving 67,571 Asian and 54,882 non-Asian patients were included. Rivaroxaban following J-ROCKET AF criteria was associated with comparable risks of thromboembolism in the Asian subgroup, whereas rivaroxaban following J-ROCKET AF criteria was associated with higher risks of all-cause mortality (HR:1.30; 95%CI:1.05–1.60) compared with that of ROCKET AF criteria in the non-Asian population. There were no differences in risks of major bleeding between rivaroxaban following J-ROCKET AF versus ROCKET AF criteria either in the Asian or non-Asian population. Use of rivaroxaban 10mg despite of CrCl>50ml/min was associated with a higher risk of thromboembolism (HR:1.64; 95%CI:1.28–2.11) but lower risk of major bleeding (HR:0.72; 95%CI:0.57–0.90) compared with eligible dosage criteria. Use of rivaroxaban 20mg despite of CrCl<50ml/min was associated with worse clinical outcomes in the risks of thromboembolism (HR:1.32; 95%CI:1.09–1.59), mortality (HR:1.33; 95%CI:1.10–1.59) and major bleeding (HR:1.26; 95%CI:1.03–1.53) compared with eligible dosage criteria. The pooled results were generally in line with the primary effectiveness and safety outcomes by removing a single study at one time. Meta-regression analyses failed to detect the bias in most potential patient characteristics associated with the clinical outcomes. Conclusions Rivaroxaban dosing regimen following J-ROCKET criteria may serve as an alternative to ROCKET-AF criteria for the Asian population with NVAF, whereas the dosing regimen following ROCKET AF criteria was more favorable for the non-Asian population. Use of rivaroxaban 10mg despite of CrCl>50ml/min was associated with a higher risk of thromboembolism but a lower risk of major bleeding, while use of rivaroxaban 20mg despite of CrCl<50ml/min was associated with worse outcome in most clinical events.