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The School for Primary Care Research has funded a study using anonymised patient data to look at the risks and benefits of modern anticoagulant drugs (Apixaban, Rivaroxaban and Dabigatran).


This is a very important study with ‘real world’ evidence on which these medications have the best safety profile. This will help doctors make better decisions when prescribing these commonly used medicines for patients in primary care.”

 - Julia Hippisley-Cox

Professor of Clinical Epidemiology and General Practice Julia Hippisley-Cox, and researchers at the Universities of Nottingham and Southampton, used patient data from the records of 150 GP practices using EMIS Web and QResearch database. The study compared the health outcomes of patients treated with three commonly-prescribed direct oral anticoagulants (DOACs) with those treated with Warfarin.

Published in the BMJ, the study gives the most comprehensive overall picture of the real-world use of anticoagulants in patients with a range of conditions, not just atrial fibrillation. Researchers analysed data from the primary care records of almost 200,000 people, comparing two large groups over a five-year period. One group had abnormal heart rhythm, the other a range of other conditions treated with anticoagulants.

The results of the study will provide important new evidence on the safety profile of the different anticoagulant medications and help doctors make better prescribing decisions.

The study found:

  • Apixaban was the safest drug, with reduced risks of major bleeds, intracranial and gastro-intestinal bleeding compared with warfarin.
  • In the group with abnormal heart rhythm, dabigatran was linked to a reduced risk of intracranial bleed, while rivaroxaban was linked to a reduced risk in the group with other conditions.
  • Rivaroxaban and low dose apixaban were associated with increased risks of all-cause mortality compared with warfarin in both groups of patients.

More work is needed to understand the implications of some of the findings for real world clinical practice.

The lead author of the study, Dr Yana Vinogradova, said: “The results of this large new study are important because previous research using randomised controlled trials has only included carefully selected patients who are closely monitored. Other observational studies have in most cases concentrated solely on patients with atrial fibrillation (abnormal heart rhythm) so until now there has been no overall picture of information for use of anticoagulants in other patients.”

Publication: Risks and benefits of direct oral anticoagulants versus warfarin in a real world setting: cohort study in primary careYana Vinogradova,Carol CouplandTrevor HillJulia Hippisley-Cox. BMJ. 5 July 2018.

Read press release from University of Nottingham.