title: Comparative efficacy and safety of anticoagulants and aspirin for extended treatment of venous thromboembolism: A network meta-analysis.
abstract: OBJECTIVE
  To systematically review the literature and to quantitatively evaluate the efficacy and safety of extended pharmacologic treatment of venous thromboembolism (VTE) through network meta-analysis (NMA).
  
  
  METHODS
  A systematic literature search (MEDLINE, Embase, Cochrane CENTRAL, through September 2014) and searching of reference lists of included studies and relevant reviews was conducted to identify randomized controlled trials of patients who completed initial anticoagulant treatment for VTE and then randomized for the extension study; compared extension of anticoagulant treatment to placebo or active control; and reported at least one outcome of interest (VTE or a composite of major bleeding or clinically relevant non-major bleeding). A random-effects Frequentist approach to NMA was used to calculate relative risks with 95% confidence intervals.
  
  
  RESULTS
  Ten trials (n=11,079) were included. Risk of bias (assessed with the Cochrane tool) was low in most domains assessed across the included trials. Apixaban (2.5mg and 5mg), dabigatran, rivaroxaban, idraparinux and vitamin K antagonists (VKA) each significantly reduced the risk of VTE recurrence compared to placebo, ranging from a 73% reduction with idraparinux to 86% with VKAs. With exception of idraparinux, all active therapies significantly reduced VTE recurrence risk versus aspirin, ranging from a 73% reduction with either apixaban 2.5mg or rivaroxaban to 80% with VKAs. Apixaban and aspirin were the only therapies that did not increase composite bleeding risk significantly compared to placebo. All active therapies except aspirin increased risk of composite bleeding by 2 to 4-fold compared to apixaban 2.5mg, with no difference found between the two apixaban doses.
  
  
  CONCLUSIONS
  Extended treatment of VTE is a reasonable approach to provide continued protection from VTE recurrence although bleeding risk is variable across therapeutic options. Our results indicate that apixaban, dabigatran, rivaroxaban, idraparinux and VKAs all reduced VTE recurrence when compared to placebo. Apixaban appears to have a more favorable safety profile compared to other therapies.
authors: University of Connecticut School of Pharmacy, Department of Pharmacy Practice, 69 North Eagleville Rd Unit 3092, Storrs, CT 06269, USA. Electronic address: Diana.sobieraj@hhchealth.org.
authors: Diana M
authors: DM
authors: Sobieraj
authors: University of Connecticut School of Pharmacy, Department of Pharmacy Practice, 69 North Eagleville Rd Unit 3092, Storrs, CT 06269, USA. Electronic address: craig.coleman@hhchealth.org.
authors: Craig I
authors: CI
authors: Coleman
authors: Case Cardiovascular Research Institute, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA. Electronic address: lepiscean@gmail.com.
authors: Vinay
authors: V
authors: Pasupuleti
authors: Medicine Institute Center for Value Based Care Research, Cleveland Clinic, Cleveland, OH, USA. Electronic address: abhishekdp@gmail.com.
authors: Abhishek
authors: A
authors: Deshpande
authors: Department of Hospital Medicine & Outcomes Research, Anesthesiology, Cleveland Clinic, Cleveland, OH, USA. Electronic address: kawr@ccf.org.
authors: Roop
authors: R
authors: Kaw
authors: Medical School, Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru, Health Outcomes and Clinical Epidemiology Section, Dept. of Quantitative Health Sciences, Lerner, Research Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address: adrianhernandezdiaz@gmail.com.
authors: Adrian V
authors: AV
authors: Hernandez
mesh_terms: D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects* / Q000145:classification / Q000627:therapeutic use; D001241:Aspirin / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D002986:Clinical Trials as Topic; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced* / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D012107:Research Design; D016896:Treatment Outcome; D054556:Venous Thromboembolism / Q000188:drug therapy*
chemical_list: D000925:Anticoagulants; D001241:Aspirin
keywords: Anticoagulant; Antiplatelet; Deep vein thrombosis; Pulmonary embolism; Venous thromboembolism