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. 2020 Aug;35(8):2329-2337.
doi: 10.1007/s11606-020-05777-3. Epub 2020 Apr 6.

Comparative Safety and Effectiveness of Direct-Acting Oral Anticoagulants Versus Warfarin: a National Cohort Study of Nursing Home Residents

Matthew Alcusky  1 , Jennifer Tjia  2 , David D McManus  2   3 , Anne L Hume  4 , Marc Fisher  5 , Kate L Lapane  2
Affiliations

Comparative Safety and Effectiveness of Direct-Acting Oral Anticoagulants Versus Warfarin: a National Cohort Study of Nursing Home Residents

Matthew Alcusky et al. J Gen Intern Med. 2020 Aug.

Abstract

Background: Research comparing direct-acting oral anticoagulants (DOACs) to warfarin has excluded nursing home residents, a vulnerable and high-risk population.

Objective: To compare the safety and effectiveness of DOACs versus warfarin.

Design: New-user cohort study (2011-2016).

Patients: US nursing home residents aged > 65 years with non-valvular atrial fibrillation enrolled in fee-for-service Medicare for > 6 months.

Exposures: Initiators of DOACs (2881 apixaban, 1289 dabigatran, 3735 rivaroxaban) were 1:1 propensity matched to warfarin initiators.

Main measures: Outcomes included ischemic stroke or transient ischemic attack (i.e., ischemic cerebrovascular event), bleeding (extracranial or intracranial), other vascular events, death, and a composite of all outcomes. Absolute rate differences (RD) and cause-specific hazard ratios (HR) with 95% confidence intervals (CI) were estimated. Subgroup analyses were performed by alignment of DOAC dosing with labeling.

Key results: Median age (84 years), CHA2DS2-Vasc (5), and ATRIA risk scores (3) were similar across medications. Clinical outcome rates were similar for dabigatran and rivaroxaban users versus warfarin users. However, ischemic cerebrovascular event rates were higher among dabigatran and rivaroxaban users that received reduced dosages without an indication. Overall, apixaban users had higher ischemic cerebrovascular event rates (HR 1.86; 95% CI 1.00-3.45) and lower bleeding rates (HR 0.66; 95% CI 0.49-0.88), but outcome rates varied by dosing alignment. Mortality rates (per 100 person-years) were lower for apixaban (RDs - 9.30; 95% CI - 13.18 to - 5.42), dabigatran (RDs - 10.79; 95% CI - 14.98 to - 6.60), and rivaroxaban (RDs - 8.92; 95% CI - 12.01 to - 5.83) versus warfarin; composite outcome findings were similar.

Conclusions: Among US nursing home residents, the DOACs were each associated with lower mortality versus warfarin. Misaligned DOAC dosing was common in nursing homes and was associated with clinical and mortality outcomes. Overall, DOAC users had lower rates of adverse outcomes including mortality compared with warfarin users.

Keywords: anticoagulants; atrial fibrillation; comparative effectiveness; nursing homes.

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Conflict of interest statement

DDM has received research grant funding from Bristol-Myers Squibb, Boeringher-Ingelheim, Pfizer, Samsung, Philips Healthcare, Philips, Biotronik, and FlexCon and has received consultancy fees from Bristol-Myers Squibb, Pfizer, Flexcon, Boston Biomedical Associates. Other authors have no relationships to disclose.

Figures

Figure 1
Figure 1
Absolute differences in clinical event, mortality, and composite outcome rates between direct-acting oral anticoagulant and warfarin users. TIA, transient ischemic attack; AMI, acute myocardial infarction; VTE, venous thromboembolism; SE, systemic embolism.
Figure 2
Figure 2
Results of Cox proportional hazards models comparing ischemic stroke/transient ischemic attack (TIA), bleeding, and mortality rates by dose between apixaban and warfarin users (top), dabigatran and warfarin users (middle), and rivaroxaban and warfarin users (bottom*). Asterisk indicates the axis for rivaroxaban versus warfarin was scaled to maintain consistency with the other plots.
See this image and copyright information in PMC

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References

    1. Connolly SJ, Ezekowitz MD, Yusuf S, et al. RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361:1139–51. - PubMed
    1. Patel MR, Mahaffey KW, Garg J, et al. ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365:883–91. - PubMed
    1. Granger CB, Alexander JH, McMurray JJ, ARISTOTLE Committees and Investigators et al. Apixaban versus warfarin. N Engl J Med. 2011;365:981–992. - PubMed
    1. Coleman CI, Peacock WF, Bunz TJ, Alberts MJ. Effectiveness and Safety of Apixaban, Dabigatran, and Rivaroxaban Versus Warfarin in Patients with Nonvalvular Atrial Fibrillation and Previous Stroke or Transient Ischemic Attack. Stroke. 2017;48(8):2142–2149. - PubMed
    1. Lip GY, Keshishian A, Li X, et al. Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients. Stroke. 2018;49(12):2933–2944. - PMC - PubMed

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