Abstract 17789: Comparative Effectiveness and Safety Between Non-Vitamin K Antagonist Oral Anticoagulants Change With Renal Function
Introduction: Non-vitamin K antagonist oral anticoagulants (NOACs) have at least equivalent efficacy for stroke prevention and less intracranial bleeding than warfarin in patients with atrial fibrillation (AF). Clinicians and patients now have a choice between NOACs, however, because NOACs were not directly compared to each other in pivotal clinical trials, there is little evidence to guide the choice.
Hypothesis: Because NOACs have various degree of renal clearance - 80% in dabigatran, 35% in rivaroxaban and 27% in apixaban, renal function may impact the comparative effectiveness and safety between NOACs.
Methods: Using a large U.S. administrative claims database, we created three propensity-score matched cohorts of AF patients who were users of NOACs between 10/1/2010-9/30/2015 (apixaban versus dabigatran [N=7,390]; apixaban versus rivaroxaban [N=7,388] and dabigatran versus rivaroxaban [N=9,414]). Cox proportional hazards models were used to compare NOACs after match, adjusting for the use of a reduced dose versus standard dose. Net clinical benefit was calculated based on the stroke and intracranial bleeding event rates.
Results: Significant interaction was found comparing apixaban to dabigatran. The net clinical benefits of using apixaban versus dabigatran increased with renal function. Both apixaban and dabigatran had positive net clinical benefits compared to rivaroxaban, but the benefit diminished with improving renal function (Table).
Conclusions: Renal function appears to be an important determinant of the relative risk and benefit between NOACs. Most AF patients, especially those with severe renal impairment, may benefit more from either apixaban or dabigatran in comparison to rivaroxaban. The choice between apixaban and dabigatran is a tradeoff between preventing stroke and avoiding intracranial bleeding. Patients with normal or mildly impaired renal function may likely benefit more from apixaban than dabigatran.
Author Disclosures: P.A. Noseworthy: None. X. Yao: None. L.R. Sangaralingham: None. N.D. Shah: None.
- © 2016 by American Heart Association, Inc.