Comparative Safety and Effectiveness of Dabigatran Versus Rivaroxaban and Apixaban Utilized Among United States Department of Defense Healthcare System Patients

Background: Non-vitamin K oral anticoagulants (NOACs) are guideline-endorsed therapies for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). Information on NOAC comparative effectiveness and safety is limited. Purpose: To compare stroke and major bleeding risks in matched NVAF patients initiating treatment of dabigatran versus rivaroxaban and apixaban, using the US Department of Defense Military Health System (MHS). Methods: Primary analysis included two standard dose cohorts derived from newly initiated adult MHS patients with NVAF based on the date of clinical approval as follows: 1) dabigatran (150 mg) or rivaroxaban (20 mg) (July 2011-June 2016) and 2) dabigatran (150 mg) or apixaban (5mg) (January 2013-June 2016). To reduce potential channeling bias, propensity score matching (PSM 1:1) was used to account for differences in baseline characteristics. Cox proportional hazard regression was utilized to estimate hazard ratios for primary outcomes of stroke and major bleeding. Re...