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23 In contrast, in atrial fibrillation studies, the novel oral anticoagulants were associated with similar risk of major bleeding (relative risk 0.88, 95% confidence interval 0.71 to 1.09).
The absolute risk difference of major bleeding relative to standard adjusted dose VKA ranged from 18 fewer to 24 more events per 1000 patients treated per year (figure 4 and see online supplementary appendix 7).
For major bleeding, edoxaban 30 mg daily, apixaban, edoxaban 60 mg daily and dabigatran 110 mg twice daily were associated with a decreased risk of major bleeding relative to standard adjusted dose VKA.
Patients whose INR strays too far from the optimal level of anticoagulation are at increased risk of experiencing a hemorrhagic or thromboembolic event [ 5], with significantly higher incidence of thromboembolism [relative risk 4.5 for INR <2.0, 95% confidence interval (CI) 3.1 6.6, P < 0.001] or major bleeding (relative risk 6.4 for INR >5.0, 2.5 16.1, P < 0.001) compared with INR 2.0 3.0 [ 6].
The absolute risk difference of major bleeding relative to standard adjusted dose VKA ranged from 18 fewer to 24 more events per 1000 patients treated, with edoxaban 30 mg daily yielding the largest absolute risk reduction and medium-dose ASA the largest absolute risk increase.
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Patients with a CrCl of 30 50 mL/min receiving higher-dose edoxaban had a lower major bleeding rate relative to warfarin (3.8 % compared with 5.1%%, respectively; HR, 0.76; 95% CI 0.58 0.99) [ 13].
MacQuaid et al. found that low-dose aspirin (LDA) increases the risk of major GI bleeding (relative risk 2.07, 95% CI: 1.61 2.66) in meta-analysis [ 8].
Rates of major bleeding were significantly reduced relative to warfarin for apixaban and both dosing regimens of edoxaban [ 42, 43].
Rivaroxaban was associated with a non-significant trend towards a higher risk of major bleeding than was enoxaparin (relative risk 1.29, 95% confidence interval 0.98 to 1.69; P=0.07) and clinically relevant non-major bleeding (1.21, 0.98 to 1.50; P=0.07).
However, there was a significant (73 %) relative reduction in major bleeding with the use of rivaroxaban compared with standard of care in these fragile patients (1.3 vs 4.5 %; HR 0.27; 95 % CI 0.13 0.54).
While there was no difference in the incidence of major and CRNM bleeding (9.4 vs 10.0 %; p = 0.27), there was a >45 % relative reduction in major bleeding with the use of rivaroxaban compared with standard of care (1.0 vs 1.7%%; p = 0.002).
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