Comparative Risk of Major Bleeding With Concomitant Use of Oral Anticoagulants and Corticosteroid Bursts

Abstract

The choice of oral anticoagulants and oral corticosteroid (OCS) burst cotherapy may influence the risk of major bleeding; however, this risk remains poorly characterized. We aimed to quantify the comparative safety of non-vitamin K oral anticoagulants (NOACs) versus warfarin on major bleeding while receiving OCS burst cotherapy among patients with atrial fibrillation. A nationwide population-based cohort study was conducted using the National Health Insurance Research Database. We examined associations between NOACs (edoxaban, apixaban, dabigartran, or rivaroxaban) or warfarin with OCS burst cotherapy and major bleeding. We measured the risk by estimating incidence, incidence risk ratios (IRRs), and adjusted hazard ratios (AHRs) after adjusting for baseline differences using overlap weighting. In this study, among 239,693 patients receiving oral anticoagulants, 50,390 (21%) received at least one OCS burst, defined as OCS use for less than 30 days, were included. A lower risk of major bleeding related to OCS burst cotherapy with NOACs versus warfarin was noted (AHR = 0.57 [95% CI = 0.52-0.61]). The greatest incidence was observed in patients with warfarin and OCS burst cotherapy (67.30 per 1000 person-years). The incidence for patients prescribing OCS burst cotherapy with edoxaban (30.36 per 1000 person-years; IRR = 0.45 [95% CI = 0.38-0.53]), apixaban (34.93 per 1000 person-years; IRR = 0.52 [95% CI = 0.45-0.60]), dabigatran (42.47 per 1000 person-years; IRR = 0.63 [95% CI = 0.56-0.72]), and rivaroxaban (46.99 per 1000 person-years; IRR = 0.70 [95% CI = 0.63-0.77]), separately, was lower than that with warfarin. The results reveal that the incidence of major bleeding was lowest for edoxaban and highest for warfarin, with notable differences in incidence rates across NOACs among patients receiving oral anticoagulants and OCS burst cotherapy.

Keywords: atrial fibrillation; major bleeding; non–vitamin K anticoagulant; oral corticosteroid; warfarin.