Benefit of DOAC over warfarin – Cardiology MCQ – Answer

Benefit of DOAC over warfarin – Cardiology MCQ – Answer

Which of the following is NOT a known advantage of direct oral anticoagulant (DOAC) over warfarin? – Correct answer: c) Lower gastrointestinal bleeding

Benefit of DOAC over warfarin in the treatment of non valvular atrial fibrillation and venous thromboembolism are now well established, but for the higher rates of gastrointestinal bleeding noted in some cases.

A meta analysis of about 72 thousand participants in four landmark trials of DOACs which included RE-LY, ROCKET AF, ARISTOTLE and ENGAGE AF-TIMI 48 trials demonstrated increased gastrointestinal bleeding with DOAC (p=0.04) [1]. Otherwise DOACs had a favourable risk benefit profile with lower intracranial hemorrhage and mortality compared to warfarin. Stroke or systemic embolism rates were 19% lower in those with non valvular atrial fibrillation treated with DOACs compared to warfarin (p<0·0001). This reduction was mainly driven by reduction in hemorrhagic stroke (p<0·0001). Major bleeding rates were similar to warfarin in this meta analysis, though gastrointestinal bleeding was higher. There is variation in the rates of gastrointestinal bleeding in DOACs used for treatment of non valvular atrial fibrillation. Dabigatran has probably a higher rate of gastrointestinal bleed compared to other DOACs.

When low dose DOACs regimens were used, overall similar reductions in stroke and systemic embolism rates compared to warfarin were noted (p=0.74). These regimens had a favourable bleeding profile (p=0.05), but significantly more ischemic strokes (p=0.045).

Back to question

Reference

1. Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, Lewis BS, Parkhomenko A, Yamashita T, Antman EM. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014 Mar 15;383(9921):955-62.