Clinical Impact of Switching From or Persisting With Rivaroxaban or Apixaban After a Bleeding Event: A Real‐World Study in Patients With Nonvalvular Atrial Fibrillation

BACKGROUND: Real-world research has identified differences in effectiveness and safety between direct oral anticoagulants (DOACs) when used to reduce risks of stroke and systemic embolism in patients with atrial fibrillation. However, treatment decisions and subsequent outcomes are poorly understood in patients with atrial fibrillation who experience bleeding when receiving a DOAC. METHODS: A retrospective observational study was conducted using US claims data from Optum's Clinformatics Data Mart Database (January 2012 through March 2024). The study population comprised adults with nonvalvular atrial fibrillation who initiated a DOAC and had a subsequent claim for bleeding. After propensity score matching, patients who persisted with the same DOAC after bleeding were compared with those who switched to another DOAC. The main outcomes were major bleeding and stroke/systemic embolism. RESULTS: Among 59 620 apixaban initiators and 21 004 rivaroxaban initiators with bleeding while on therapy, 408 apixaban-to-rivaroxaban switchers were matched with 2040 persistent apixaban users, and 901 rivaroxaban-to-apixaban switchers were matched with 4505 persistent rivaroxaban users. Compared with persisting with apixaban following a bleeding event, apixaban-to-rivaroxaban switching was associated with a higher risk of major bleeding (hazard ratio [HR], 1.690 [95% CI, 1.130-2.527]) and a similar risk of stroke/systemic embolism (HR, 1.793 [95% CI, 0.765-4.202]). Compared with persisting with rivaroxaban, rivaroxaban-to-apixaban switching was associated with a lower risk of major bleeding (HR, 0.651 [95% CI, 0.460-0.920]) and a similar risk of stroke/systemic embolism (HR, 0.783 [95% CI, 0.371-1.652]). CONCLUSIONS: These findings suggest that the choice of DOAC after a bleeding event can affect treatment outcomes in patients with atrial fibrillation.