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The anticoagulant apixaban (Eliquis; Bristol Myers Squibb and Pfizer) is safer than rivaroxaban (Xarelto; Bayer) for the treatment of venous thrombosis, study results have revealed.
Publishing the findings of the study in the New England Journal of Medicine on 12 March 2026, researchers in Canada compared the rates of clinically relevant bleeding during a three-month period of patients taking either direct oral anticoagulant (DOAC) and found that apixaban has a reduced risk of bleeding events.
The researchers analysed data from 2,760 people with acute symptomatic pulmonary embolism or proximal deep-vein thrombosis from Canada, Australia and Ireland. Apixapan was given to 1,370 patients, while 1,390 patients received rivaroxaban.
During the three-month period, the researchers observed that 7.1% of patients who took rivaroxaban experienced “clinically relevant bleeding”, compared with 3.3% of patients who received apixaban.
The results showed no significant difference between the two in the risk of recurrent blood clots.
Lana A Castellucci, lead study author and senior scientist and thrombosis physician at the Ottawa Hospital, commented: “These results clearly show that apixaban is the safer option for treating venous thrombosis.
“This trial provides highly anticipated evidence for physicians and should bring real peace of mind to venous thrombosis patients, who often live with the dual fear of blood clot recurrence and bleeding.”
Co-author Marc Rodger, physician-in-chief at the McGill University Health Centre in Montreal, Canada, said: “This practice-changing trial and its findings exemplify the powerful impact of academically led, government-funded clinical research in addressing questions that truly matter to patients.”
Paul Wright, consultant cardiovascular pharmacist at Barts Health NHS Trust, described the trial as a “pragmatic design to reflect real-world practice”.
“[These results] … reflect the bleeding rates seen in previous VTE [venous thromboembolism] trials of the single agents, namely AMPLIFY (apixaban versus warfarin) and EINSTEIN studies (rivaroxaban vs. warfarin).
“The top line results suggest that, in terms of efficacy, they are similar with less bleeding events noted with apixaban. Given that this is only a three-month trial and [there were] differences in the duration of a loading dose (one week for apixaban vs. three weeks for rivaroxaban) I feel much of the bleeding difference seen was due to the differences in the loading dose.
“Current National Institute for Health and Care Excellence (NICE) guidance for the VTE diagnosis and management lists both as an option depending on patient factors.
“In practice, both are available generically and most formularies likely to reflect current NICE guidance list both as an option but given the results of this trial there is likely to be a preference now to place apixaban over rivaroxaban in future updated guidance.
“It’s important [to note that] these results are not generalisable outside of VTE treatment for the first three months and I would welcome future studies of extended use and in other indications, such as atrial fibrillation, to determine whether these results are replicated over a longer time period and in the absence of a loading dose.
“It would also be great to see individuals with excess body weight (over 120kg) included in future studies as these were excluded in the current trial,” he added.
Read more: ‘Prescribing dilemma: balancing risk and benefit when prescribing anticoagulation in an older patient with falls risk‘.
