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Presentation Details
| Apixaban vs Rivaroxaban for Venous Thromboembolism in Gastrointestinal Cancer: A Systematic Review and Meta-Analysis Ursula Medeiros Araujo de Matos1, Pedro Luiz Lage Bodour Danielian2, Moana Divina da SIlva Santiago1, Nicole Sequeira1. 1Internal Medicine Department, University of Connecticut, Farmington, CT, USA.2Harvard T.H.Chan School of Public Health, Boston, MA, USA |
Abstract
Introduction
Patients with gastrointestinal (GI) cancers have among the highest rates of cancer-associated venous thromboembolism (VTE), while also carrying a heightened risk of bleeding due to tumor-related mucosal disruption and treatment-associated factors. Direct oral anticoagulants (DOACs) are increasingly used in this population, yet comparative safety concerns remain unresolved. Apixaban may offer a more favorable bleeding profile, but evidence specific to GI malignancies is limited and heterogeneous. To address this gap, we performed a systematic review and meta-analysis evaluating the efficacy and safety of apixaban versus rivaroxaban in patients with GI cancers.
Methods
We systematically searched PubMed, Embase, Cochrane CENTRAL, and major hematology conference proceedings for randomized or observational studies comparing apixaban with rivaroxaban for VTE prevention or treatment among adults with GI malignancies. Eligible studies reported at least one of the following outcomes: recurrent VTE, major bleeding, or clinically relevant non-major bleeding (CRNMB). Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Subgroup analyses were conducted for luminal GI cancers (esophageal, gastric, small bowel, colorectal) versus non-luminal hepatopancreatobiliary malignancies. Apixaban served as the intervention and rivaroxaban as the control.
Results
Three observational studies met our inclusion criteria and a pooled total of 996 patients were analyzed. Across included studies, apixaban demonstrated comparable efficacy to rivaroxaban for VTE prevention. The pooled analysis showed no significant difference in recurrent VTE, with an OR of 0.80 (95% CI 0.42–1.51), indicating similar antithrombotic effectiveness between agents. Safety outcomes favored apixaban. Major bleeding occurred less frequently among patients receiving apixaban, with a pooled OR of 0.54 (95% CI 0.29–1.03), revealing a strong directional trend toward reduced bleeding risk, although not statistically significant. Similarly, CRNMB was lower with apixaban, with an OR of 0.40 (95% CI 0.16–1.01), suggesting a potentially meaningful reduction in non-major but clinically impactful bleeding events.
Subgroup analyses revealed differences based on tumor location. Among patients with luminal GI cancers, the risk of major bleeding did not differ significantly between treatments (OR 1.23, 95% CI 0.43–3.50). However, in non-luminal GI cancers, apixaban was associated with a significantly lower risk of major bleeding (OR 0.28, 95% CI 0.08–0.94). For CRNMB, both luminal (OR 0.53, 95% CI 0.20–1.38) and non-luminal (OR 0.47, 95% CI 0.09–2.35) subgroups showed nonsignificant but directionally consistent reductions with apixaban. Across all analyses, apixaban consistently demonstrated a safety profile that numerically favored reduced bleeding without compromising efficacy.
Conclusion
In patients with GI malignancies, apixaban provides similar protection against recurrent VTE compared with rivaroxaban and demonstrates a consistent trend toward reduced major bleeding and CRNMB. The bleeding advantage appears most pronounced in non-luminal GI cancers. These findings suggest that apixaban may offer a safer anticoagulation strategy for GI cancer–associated thromboprophylaxis, though confirmatory prospective studies are warranted.
No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author.
Patients with gastrointestinal (GI) cancers have among the highest rates of cancer-associated venous thromboembolism (VTE), while also carrying a heightened risk of bleeding due to tumor-related mucosal disruption and treatment-associated factors. Direct oral anticoagulants (DOACs) are increasingly used in this population, yet comparative safety concerns remain unresolved. Apixaban may offer a more favorable bleeding profile, but evidence specific to GI malignancies is limited and heterogeneous. To address this gap, we performed a systematic review and meta-analysis evaluating the efficacy and safety of apixaban versus rivaroxaban in patients with GI cancers.
Methods
We systematically searched PubMed, Embase, Cochrane CENTRAL, and major hematology conference proceedings for randomized or observational studies comparing apixaban with rivaroxaban for VTE prevention or treatment among adults with GI malignancies. Eligible studies reported at least one of the following outcomes: recurrent VTE, major bleeding, or clinically relevant non-major bleeding (CRNMB). Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Subgroup analyses were conducted for luminal GI cancers (esophageal, gastric, small bowel, colorectal) versus non-luminal hepatopancreatobiliary malignancies. Apixaban served as the intervention and rivaroxaban as the control.
Results
Three observational studies met our inclusion criteria and a pooled total of 996 patients were analyzed. Across included studies, apixaban demonstrated comparable efficacy to rivaroxaban for VTE prevention. The pooled analysis showed no significant difference in recurrent VTE, with an OR of 0.80 (95% CI 0.42–1.51), indicating similar antithrombotic effectiveness between agents. Safety outcomes favored apixaban. Major bleeding occurred less frequently among patients receiving apixaban, with a pooled OR of 0.54 (95% CI 0.29–1.03), revealing a strong directional trend toward reduced bleeding risk, although not statistically significant. Similarly, CRNMB was lower with apixaban, with an OR of 0.40 (95% CI 0.16–1.01), suggesting a potentially meaningful reduction in non-major but clinically impactful bleeding events.
Subgroup analyses revealed differences based on tumor location. Among patients with luminal GI cancers, the risk of major bleeding did not differ significantly between treatments (OR 1.23, 95% CI 0.43–3.50). However, in non-luminal GI cancers, apixaban was associated with a significantly lower risk of major bleeding (OR 0.28, 95% CI 0.08–0.94). For CRNMB, both luminal (OR 0.53, 95% CI 0.20–1.38) and non-luminal (OR 0.47, 95% CI 0.09–2.35) subgroups showed nonsignificant but directionally consistent reductions with apixaban. Across all analyses, apixaban consistently demonstrated a safety profile that numerically favored reduced bleeding without compromising efficacy.
Conclusion
In patients with GI malignancies, apixaban provides similar protection against recurrent VTE compared with rivaroxaban and demonstrates a consistent trend toward reduced major bleeding and CRNMB. The bleeding advantage appears most pronounced in non-luminal GI cancers. These findings suggest that apixaban may offer a safer anticoagulation strategy for GI cancer–associated thromboprophylaxis, though confirmatory prospective studies are warranted.
No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author.