Comparative Effectiveness and Safety of Direct Oral Anticoagulants
versus Warfarin in Patients with Atrial Fibrillation and Stage III
Chronic Kidney Disease
Abstract
Aim: The effectiveness and safety of direct oral anticoagulants (DOACs)
in atrial fibrillation (AF) patients with stage III chronic kidney
disease (CKD) are still subject to debate. We therefore assessed and
compared the effectiveness and safety of DOACs vs. warfarin in this
population. Methods: A cohort of patients with an inpatient or
outpatient code for AF and stage III CKD who were newly prescribed an
oral anticoagulant (OAC) was created using administrative databases from
the Quebec province of Canada between 2013 and 2017. The primary
effectiveness outcome was a composite of ischemic stroke, systemic
embolism, and death, whereas the primary safety outcome was a composite
of major bleeding within a year of DOAC vs. warfarin initiation.
Treatment groups were compared in an on-treatment analysis using inverse
probability of treatment weighting and Cox proportional hazards.
Results. A total of 8,899 included patients filled a new OAC claim:
3,335 for warfarin and 5,564 DOACs. Compared with warfarin, rivaroxaban
15 mg and 20 mg presented a similar effectiveness and safety composite
risk. Apixaban 5.0 mg was associated with a lower effectiveness
composite risk (Hazard ratio [HR] 0.76; 95% confidence interval
[CI] 0.65–0.88) and a similar safety risk (HR 0.94; 95% CI
0.66–1.35), whereas apixaban 2.5 mg was associated with a similar
effectiveness composite (HR 1.00; 95% CI 0.79–1.26) and a lower safety
risk (HR 0.65; 95% CI 0.43–0.99). Conclusion: In comparison with
warfarin, rivaroxaban and apixaban appear to be effective and safe in AF
patients with stage III CKD.