Blood Thinners for Atrial Fibrillation (AFib): Which Is Best?

Atrial fibrillation (AFib) is the most commonly treated heart arrhythmia (irregular heartbeat). One of the main goals of treatment is to prevent stroke — a big risk associated with the condition. Someone with AFib may be up to five times more likely to have a stroke.

A group of medications called anticoagulants are prescribed to prevent the blood clots that lead to stroke in AFib. They’re part of a broader group of medications more commonly referred to as blood thinners.

For many years, warfarin (Coumadin, Jantoven) was the blood thinner of choice in AFib. But a newer group of medications called direct oral anticoagulants (DOACs) are a better option for most people now.

Here, we’ll review the various blood thinners for AFib, and some pros and cons of each.

Are blood thinners recommended if you have AFib?

Yes, most people with AFib take a blood thinner to prevent a type of stroke called an ischemic stroke. An ischemic stroke occurs when blood flow to the brain is blocked, often by a clot. 

In AFib, you’re at higher risk of blood clots because it can affect the way blood flows through the heart. This can cause blood to pool inside the heart chambers, forming a clot. Blood thinners lower the risk of blood clots forming in the body, therefore lowering the risk of stroke.

EXPERT PICKS: WHAT TO READ NEXT

• Your guide to atrial fibrillation (AFib). Learn all about AFib, including what it is, how it’s diagnosed, and how to treat it. 

• Blood thinner facts: There are a variety of blood thinner options to choose from. Learn a few facts about the most commonly used ones.

• Blood thinner interactions. Learn about common blood thinner drug interactions to watch for.

Blood thinners used to treat AFib

Several blood thinners can prevent stroke in AFib. This includes warfarin and several DOACs, namely:

• Pradaxa (dabigatran)

• Eliquis (apixaban)

• Xarelto (rivaroxaban)

• Savaysa (edoxaban)

Warfarin was first FDA approved in the 1950s. It’s classified as a vitamin K antagonist, and it works by blocking the activation of vitamin K. The body uses activated vitamin K to make blood clots.

DOACs prevent blood clots in a different way. Think of it like a domino rally. Warfarin focuses on stopping the rally at the very beginning. DOACs focus on removing certain dominoes in the middle.

Warfarin vs. DOACs in AFib: Which is best?

DOACs are now the preferred blood thinner for preventing stroke in AFib. But there are potential downsides compared to warfarin as well.

Advantages of DOACs vs. warfarin

Some advantages of DOACs versus warfarin include:

• Lower risk of stroke: DOACs work just as well as or better than warfarin at preventing stroke in people with AFib.

• Lower risk of death: When it comes to overall mortality rate, DOACs are associated with a lower risk of death than warfarin. 

• Risk of bleeding in the brain: DOACs may have a lower risk of brain bleeds compared to warfarin.

• Decreased major bleeding risk: Major bleeding is any bleeding that warrants prompt medical treatment. Some research suggests that certain DOACs have a lower risk of major bleeding than warfarin.

• Less monitoring and fewer checkups: People taking DOACs don’t require as many blood tests as those taking warfarin.

• Faster onset: DOACs start working faster than warfarin does. It can take warfarin several days to get to the right level in the body.

• Stopping the medication more easily: DOAC effects don’t last as long as warfarin once you stop taking them. This is a good thing if you’re having surgery and need to stop your blood thinner in advance.

• Fewer drug and food interactions: People who take warfarin need to pay special attention to their diet and other medications. While DOACs also have possible drug interactions, they aren’t known to interact with foods.

Disadvantages of DOACs vs. warfarin

DOACs have several advantages over warfarin. But there are potential downsides as well. For example:

• Higher gastrointestinal (GI) bleeding risk: Studies comparing Pradaxa, Xarelto, and Savaysa to warfarin showed that these DOACs are more likely to cause GI bleeding than warfarin. Eliquis has been shown to have a lower risk..

• Harder to reverse bleeding: If you experience life-threatening bleeding, there are medications that can help quickly reverse the effect of the blood thinner in your body. There are different medications depending on which blood thinner you’re taking, and they all need to be given in a hospital. But some of the reversal medications for DOACs may be more expensive and less readily available.

• Higher cost: Warfarin and Pradaxa are available as generic medications. Other DOACs are brand-name only. While there are several ways to save on DOACs, warfarin is typically the most affordable blood thinner if you’re paying cash.

Despite some of these downsides, DOACs are the best anticoagulant for most people with AFib.

When is warfarin preferred over DOACs for AFib?

For some people, warfarin is the best blood thinner for AFib treatment. This includes people who have:

• Mechanical heart valves

• Moderate-to-severe mitral valve stenosis

• Antiphospholipid syndrome, an autoimmune disorder that makes your blood more likely to clot

Comparing DOACs: Is there a difference between Pradaxa vs. Eliquis vs. Xarelto?

Overall, DOACs are more similar to each other than they are different. They’re considered equally effective at preventing stroke and death in people with AFib. 

A few major differences include:

• Risk of stomach bleeding: Some research shows that Eliquis has a lower risk of stomach bleeding compared to Pradaxa and Xarelto.

• Risk of major bleeding: Xarelto has been found to have a higher risk of major bleeding than Pradaxa and Eliquis.

• Use in kidney disease: Eliquis or Savaysa may be the best DOACs for people with kidney disease.

• Use in liver disease: Xarelto and Savaysa aren’t recommended in moderate-to-severe liver disease. Warfarin, Pradaxa, or Eliquis may be a better choice.

• Taking with food: Xarelto is the only DOAC that needs to be taken with meals. And since stomach upset is common with Pradaxa, it may help to take Pradaxa with food as well.

• Dosage frequency: Savaysa and Xarelto are only taken once a day, while Eliquis and Pradaxa are typically taken twice a day for AFib.

What are the side effects of DOACs and warfarin?

The primary side effect of all blood thinners is abnormal bruising or bleeding. This may include bleeding from the:

• Gums

• Nose

• Stomach, intestine, or rectum

• Bladder

• Uterus, or increased menstrual bleeding 

Contact your prescriber immediately if you develop unusual bleeding at any point. They can help you determine how serious it is.

If bleeding seems severe or doesn’t stop, call 911 or seek emergency care instead.

Other side effects

Bleeding aside, specific side effects vary by medication. Your prescriber can walk you through what to expect.

For instance, Eliquis may cause nausea, while Xarelto may cause stomach and back pain. GI side effects like upset stomach, heartburn, and abdominal pain are more common with Pradaxa. GI-related side effects, such as nausea and diarrhea, are possible with warfarin.

Are blood thinners safe for long-term use?

Yes, most people take blood thinners long term for AFib. In many cases, the benefits of taking blood thinners long term — such as lowered risk of stroke, death, and more — outweigh the risk of bleeding. But individual circumstances can change as you age or develop other health conditions.

You and your healthcare team should routinely reassess the benefits and risks of taking a blood thinner.

Make sure to keep up with any office or laboratory appointments your prescriber recommends to monitor your blood thinner medication. This will help your prescriber make sure you’re taking the best dose for you.

Are there alternatives to blood thinners for AFib?

At this time, there’s no alternative to warfarin or DOACs for preventing blood clots in AFib. But some people may qualify for a procedure called a left atrial appendage (LAA) occlusion, which may eliminate the need for blood thinners.

A LAA occlusion procedure involves placing a small, umbrella-like device in a part of the heart called the left atrial appendage. This prevents the formation of blood clots in that area, where most blood clots in AFib start.

However, not everyone is a candidate for an LAA occlusion procedure. As of now, it’s typically only recommended for people who can’t tolerate DOACs, or whose bleeding risk is too high to take a DOAC.

How to save

Warfarin is typically less expensive than DOACs. For example, 30 tablets of 5 mg generic warfarin may cost as low as $4.00 at certain pharmacies with a free GoodRx discount.

The only DOAC that’s currently available as a lower-cost generic medication is Pradaxa. A one-month supply of generic Pradaxa may cost around $65.52 at some pharmacies with a free GoodRx discount.

There are still ways to save on DOACs that are brand-name only:

• Eliquis: If you have commercial insurance, you could pay as little as $10 per Eliquis prescription with a savings card from the manufacturer. A free trial offer is also available. If you’re uninsured or underinsured, you may be able to receive Eliquis for free through a patient assistance program.

• Xarelto: If you have commercial insurance, you could pay as little as $10 for your monthly prescription with a savings card from the manufacturer. A patient assistance program is also available.

• Savaysa: If you have commercial insurance, you could pay as little as $4 for your monthly prescription with a savings card from the manufacturer.

Why trust our experts?

Written by:

Amy B. Gragnolati, PharmD, BCPS

Amy Gragnolati, PharmD, BCPS, is a pharmacy editor for GoodRx. Amy currently holds her pharmacist license in Georgia and California.

Reviewed by:

Katie E. Golden, MD

Katie E. Golden, MD, is a board-certified emergency medicine physician and a medical editor at GoodRx.

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