Comparative effectiveness and safety of rivaroxaban with other oral anticoagulants in older adults with nonvalvular atrial fibrillation: Population-based analysis in response to updated Beers criteria.

Objective: Given recent concerns regarding the updated Beers Criteria, we sought to compare the effectiveness and safety of rivaroxaban with oral anticoagulants in older adults with nonvalvular atrial fibrillation (AF).

Methods: We used an administrative healthcare database and included AF patients ≥ 65 years who were new users of rivaroxaban or the comparators. We created three pairwise comparisons: rivaroxaban vs. warfarin; rivaroxaban vs. dabigatran; and rivaroxaban vs. apixaban. Study outcomes included stroke or systemic embolism (effectiveness), and gastrointestinal or intracranial bleeding (safety). In the propensity score matched sample, we used Cox proportional hazards regression to estimate hazard ratios [HRs] and 95% confidence intervals [CIs].

Results: In the matched cohorts, use of rivaroxaban (vs. warfarin) increased risk of bleeding (HR 1.13; CI 1.03 to 1.23) with no difference in ischemic stroke or systemic embolism (HR 0.90; CI 0.79 to 1.02); use of rivaroxaban (vs. dabigatran) increased risk of bleeding (HR 1.18; CI 1.03 to 1.35) with no difference in ischemic stroke and systemic embolism (HR 1.00; CI 0.83 to 1.22); and use of rivaroxaban (vs. apixaban) increased risk of stroke and systemic embolism (HR 1.23; CI 1.08 to 1.40) and bleeding (HR 1.60; CI 1.45 to 1.76).

Conclusion: In this comparative effectiveness and safety study of older patients with nonvalvular AF, use of rivaroxaban was associated with a significantly increased risk of ischemic stroke and systemic embolism compared with apixaban, and bleeding compared with warfarin, dabigatran, and apixaban. Our findings may inform anticoagulant selection in older adults with nonvalvular AF.