• Michael Fralick, Michael Colacci, Sebastian Schneeweiss, Krista F Huybrechts, Kueiyu Joshua Lin, and Joshua J Gagne.
• Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, and Sinai Health System and University of Toronto, Toronto, Ontario, Canada (M.F.).
• Ann. Intern. Med. 2020 Apr 7; 172 (7): 463473463-473.

BackgroundApixaban and rivaroxaban are the most commonly prescribed direct oral anticoagulants for adults with atrial fibrillation, but head-to-head data comparing their safety and effectiveness are lacking.ObjectiveTo compare the safety and effectiveness of apixaban versus rivaroxaban for patients with nonvalvular atrial fibrillation.DesignNew-user, active-comparator, retrospective cohort study.SettingA U.S. nationwide commercial health care claims database from 28 December 2012 to 1 January 2019.PatientsAdults newly prescribed apixaban (n = 59 172) or rivaroxaban (n = 40 706).MeasurementsThe primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial hemorrhage or gastrointestinal bleeding.Results39 351 patients newly prescribed apixaban were propensity score matched to 39 351 patients newly prescribed rivaroxaban. Mean age was 69 years, 40% of patients were women, and mean follow-up was 288 days for new apixaban users and 291 days for new rivaroxaban users. The incidence rate of ischemic stroke or systemic embolism was 6.6 per 1000 person-years for adults prescribed apixaban compared with 8.0 per 1000 person-years for those prescribed rivaroxaban (hazard ratio [HR], 0.82 [95% CI, 0.68 to 0.98]; rate difference, 1.4 fewer events per 1000 person-years [CI, 0.0 to 2.7]). Adults prescribed apixaban also had a lower rate of gastrointestinal bleeding or intracranial hemorrhage (12.9 per 1000 person-years) compared with those prescribed rivaroxaban (21.9 per 1000 person-years), corresponding to an HR of 0.58 (CI, 0.52 to 0.66) and a rate difference of 9.0 fewer events per 1000 person-years (CI, 6.9 to 11.1).LimitationUnmeasured confounding, incomplete laboratory data.ConclusionIn routine care, adults with atrial fibrillation prescribed apixaban had a lower rate of both ischemic stroke or systemic embolism and bleeding compared with those prescribed rivaroxaban.Primary Funding SourceDivision of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital.

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