Efficacy and safety of oral anticoagulants in atrial fibrillation patients with cancer—a network meta-analysis

There are no guideline recommendations for the use of anticoagulant therapy in atrial fibrillation (AF) patients with cancer, which creates uncertainty about the optimal antithrombotic treatment in these patients. We conducted a network meta-analysis for the first time to assess the efficacy and safety of anticoagulant drugs in patients with AF and concurrent cancer. The PubMed, EMBASE, and Cochrane databases were searched up to March 2019. A search was made for the main anticoagulant drugs (warfarin, dabigatran, apixaban, rivaroxaban, and edoxaban). Outputs were presented as odds ratios (ORs), their corresponding 95% confidence intervals (CIs), and the surface under the cumulative ranking area (SUCRA) probabilities. We identified 414 relevant studies and included 5 trials involving 31,660 participants. In reducing the risk of stroke or systemic embolism, rivaroxaban and apixaban ranked the best and second best (SUCRA, 25.2% and 29.3%, respectively), followed by dabigatran, edoxaban, and warfarin. Apixaban and dabigatran were associated with lower probability of achieving at venous thromboembolism (VTE) (OR 0.12, 95% CI 0.05–0.52, SUCRA, 0.1%; and OR 0.24, 95% CI 0.07–1.00, SUCRA, 33.3%, respectively) than warfarin (SUCRA, 100.0%). For the prevention of all-cause death, apixaban was nonsignificantly less likely than warfarin. In addition, there were nonsignificant differences among all interventions in major bleeding, with the exception of apixaban vs. warfarin (OR 0.39, 95% CI 0.18–0.79; SUCRA 4.9%). In AF patients with cancer, nonvitamin K antagonist oral anticoagulants showed a lower incidence of stroke/systemic embolism, VTE, all-cause death, and major bleeding than warfarin, with apixaban being the best of those studied.