Rivaroxaban versus apixaban in non‐valvular atrial fibrillation patients with end‐stage renal disease or receiving dialysis

Abstract

Objectives We sought to evaluate the effectiveness and safety of rivaroxaban vs apixaban in non‐valvular atrial fibrillation (NVAF) patients with end‐stage renal disease (ESRD) and/or receiving dialysis in routine practice. Methods Using US MarketScan claims data from January 1, 2014, to December 31, 2017, we identified new‐users of rivaroxaban or apixaban during 2015 with at least 12 months of insurance coverage prior to oral anticoagulant (OAC) initiation. Differences in baseline covariates between cohorts were adjusted using inverse probability‐of‐treatment weighting based on propensity scores. Patients were followed for stroke or systemic embolism (SSE) or major bleeding hospitalizations. Cox proportion hazards regression was used to compare rivaroxaban and apixaban. Analyses stratified by age, sex, CHA2DS2‐VASc score, prior stroke, prior bleed, diabetes, and reduced OAC dose were performed. Results We identified 787 rivaroxaban and 1836 apixaban users. Median (25, 75% range) age = 70 (61, 79), CHA2DS2‐VASc score = 3 (2, 4), and follow‐up = 0.87 (0.38, 1.56) years. No differences in the risks of SSE (HR = 1.18, 95% CI = 0.53‐2.63), ischemic stroke (HR = 1.12, 95%CI = 0.45‐2.76), or major bleeding (HR = 1.00, 95% CI = 0.63‐1.58) were observed. No significant interactions were observed upon subgroup analysis. Conclusion In NVAF patients with ESRD and/or receiving dialysis, rivaroxaban and apixaban were associated with similar risks of SSE and major bleeding.

Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy

“…Miao B et al compared rivaroxaban and apixaban in ESRD patients. No significant differences were reported in terms of thromboembolic and hemorrhagic risk [31]; however, when compared to warfarin, rivaroxaban appears to be associated with a reduction of major bleeding [104]. Furthermore, a meta-analysis enrolling 71,877 patients on long-term dialysis and with AF showed that patients receiving apixaban 5 mg twice daily had a significantly lower risk of mortality than those receiving apixaban 2.5 mg twice daily, warfarin or no anticoagulant and lower bleeding risk than those on warfarin, dabigatran or rivaroxaban [105].…”

“…Randomized controlled trials demonstrated that direct oral anticoagulants (DOACs) are not inferior to warfarin for stroke or systemic embolism; however, these studies excluded patients on dialysis, those with an eGFR < 25-30 mL/min and those treated with vitamin K antagonists (VKA) other than warfarin [20][21][22][23][24][25]. Consequently, all data concerning use of DOACs in patients with eGFR < 30 mL/min came from observational studies, and the evidence in favor of DOACs in patients with advanced or ESRD is still very limited [26][27][28][29][30][31]. The aim of this review is to evaluate how treatment with DOACs affects stroke and bleeding outcomes compared with warfarin in a CKD population.…”

Direct Oral Anticoagulants in the Treatment of Venous Thromboembolism: Use in Patients with Advanced Renal Impairment, Obesity, or Other Weight-Related Special Populations

“…This conclusion is supported by a study comparing rivaroxaban to apixaban in 2,623 patients with NVAF and stage 5 CKD. 55 Rates of stroke and systemic embolism and major bleeding were nearly identical and not significantly different (►Table 3). Most of the patients (71%) received full-dose rivaroxaban and apixaban.…”

“…There have been several observational/real-world studies evaluating the efficacy and safety of DOACs in the setting of renal dysfunction (►Table 3). [42][43][44][45][46][47][48][49][50][51][52][53][54][55][56] Observational studies are prone to bias, with studies that are small, have inconsistent or short follow-up, single-center, or have unmatched patients being more susceptible. Unfortunately, data specifically in patients with VTE are extremely limited, with most studies evaluating patients with NVAF.…”

Direct Oral Anticoagulants in Atrial Fibrillation: Practical Considerations and Remaining Issues

“…23,24 • Although studies in this field were inconsistent in study design and quality, this questions the need for anticoagulation in dialysis patients in general and data from an ongoing randomized trial will hopefully clarify the role for VKA in this setting (NCT02886962). • Evidence for using DOACs in ESRD and dialysis patients is emerging and, so far, has indicated a potential for benefit, [25][26][27] although negative results have also been reported. 28,29 Which Drug-Drug Interactions Are Relevant?…”