FPIN's Clinical Inquiries
Rivaroxaban vs. Warfarin for Treatment of DVT and PE
Am Fam Physician. 2017 Oct 15;96(8):532-533.
Is rivaroxaban (Xarelto) as effective as vitamin K antagonists for the treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE)?
Rivaroxaban, along with the other factor Xa inhibitors, is as effective as or better in the short term (three months) than warfarin (Coumadin) for preventing recurrent DVT, nonfatal PE, and fatal PE, with no differences in mortality or bleeding events. (Strength of Recommendation: A, based on consistent, high-quality meta-analyses of moderate- to high-quality randomized controlled trials [RCTs] with patient-oriented outcomes.)
A 2015 Cochrane meta-analysis of 11 RCTs (N = 27,945) compared direct thrombin inhibitors, factor Xa inhibitors (rivaroxaban, apixaban [Eliquis], and edoxaban [Savaysa]), and standard anticoagulants (unfractionated heparin, low-molecular-weight heparin, and vitamin K antagonists such as warfarin) in the treatment of venous thromboembolism (VTE) and PE.1 Eight of the RCTs (N = 16,356) compared factor Xa inhibitors with standard anticoagulants; four (N = 9,428) compared rivaroxaban with standard anticoagulants (international normalized ratio goal of 2 to 3). Primary outcomes included recurrent VTE, recurrent DVT, and fatal and nonfatal PE. After three months, there was a significant trend in favor of factor Xa inhibitors compared with warfarin for the prevention of recurrent VTE (five trials, three with rivaroxaban; N = 5,001; odds ratio [OR] = 0.69; 95% confidence interval [CI], 0.48 to 0.99) and recurrent DVT (four trials, two with rivaroxaban; N = 4,917; OR = 0.51; 95% CI, 0.31 to 0.84). When treatment was extended beyond three months, there were no significant differences in rates of recurrent VTE (three trials, one with rivaroxaban; N = 11,355; OR = 0.97; 95% CI, 0.78 to 1.22) or recurrent DVT (three trials, one with rivaroxaban; N = 11,355; OR = 0.87; 95% CI, 0.63 to 1.20) compared with warfarin. Overall, there was a significant decrease in rates of recurrent VTE with factor
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REFERENCESshow all references
1. Robertson L, Kesteven P, McCaslin JE. Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of deep vein thrombosis. Cochrane Database Syst Rev. 2015;(6):CD010956....
2. Robertson L, Kesteven P, McCaslin JE. Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of pulmonary embolism. Cochrane Database Syst Rev. 2015;(12):CD010957.
3. Cohen AT, Hamilton M, Bird A, et al. Comparison of the non-VKA oral anticoagulants apixaban, dabigatran, and rivaroxaban in the extended treatment and prevention of venous thromboembolism: systematic review and network meta-analysis [published correction appears in PLoS One. 2016;11(9):e0163386]. PLoS One. 2016;11(8):e0160064.
4. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315–352.
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