Comparative Efficacy and Safety of Direct Oral Anticoagulants and Warfarin for the Treatment of Deep Venous Thrombosis and the Prevention of Post-Thrombotic Syndrome

Abstract

In recent years, clinical trials have shown that direct oral anticoagulants (DOACs) are at least as effective and safe as oral warfarin for the treatment of venous thromboembolism (VTE). However, there are few studies comparing efficacy and safety of different DOACs for VTE. The purpose of this study was to compare antithrombotic and hemorrhagic effects of different DOACs and warfarin in patients with acute deep venous thrombosis (DVT). In addition, we studied preventive effects of these anticoagulants on the post-thrombotic syndrome (PTS). Consecutive patients with acute DVT who were treated with anticoagulants were enrolled. The cumulative incidence of VTE recurrence and bleeding events was assessed. Furthermore, we assessed cumulative complete thrombus resolution and development of PTS. During the 3-year period, 264 patients were treated with anticoagulation alone. Of these, 69 patients (26%) received apixaban, 64 (24%) received edoxaban, 67 (25%) received rivaroxaban, and 64 (25%) received warfarin. There were no significant differences in mean age (P = .131), sex distribution (P = .858), body mass index (P = .392), distribution of DVT (proximal vs distal, P = .072), proportion of concomitant pulmonary embolism (P = .317), and duration of anticoagulation (P = .117) between the groups. The higher incidence of the recurrent VTE was found in the warfarin group; however, this was not statistically significant (log-rank, P = .478). Similarly, bleeding events were more common in the warfarin and rivaroxaban groups, and fewer bleeding complications were noted in the apixaban group; this did not result in any significant difference (log-rank, P = .303). In contrast, apixaban showed earlier thrombus resolution, and the cumulative thrombus resolution was highest in the apixaban group, followed by the rivaroxaban group (log-rank, P = .022,). Development of PTS was higher in the rivaroxaban and warfarin groups, but no significant difference was found in cumulative development of PTS (log-rank, P = .943). Although DOACs did not appear to differ in the recurrent VTE events, the bleeding complications, and the development of PTS, apixaban showed the earliest thrombus resolution among the anticoagulants studied. These results suggest that apixaban seems to be safer and more effective than some of its competitors in the management of acute DVT.