Dabigatran and Rivaroxaban Use in Atrial Fibrillation Patients on Hemodialysis
Background—Dabigatran and rivaroxaban are new oral anticoagulants that are eliminated through the kidneys. Their use in dialysis patients is discouraged because these drugs can bio-accumulate to precipitate inadvertent bleeding. We wanted to determine if prescription of dabigatran or rivaroxaban was occurring in the dialysis population and if these practices were safe.
Methods and Results—Prevalence plots were used to describe the point prevalence (monthly) of dabigatran and rivaroxaban use among 29,977 hemodialysis patients with atrial fibrillation (AF). Poisson regression compared the rate of bleeding, stroke, and arterial embolism in patients who started dabigatran, rivaroxaban, or warfarin. The first record of dabigatran prescription among hemodialysis patients occurred 45 days after the drug became available in the US. Since then, dabigatran and rivaroxaban use in the AF-ESRD population has steadily risen where 5.9% of anti-coagulated dialysis patients are started on dabigatrian or rivaroxaban. In covariate adjusted Poisson regression, dabigatran (RR=1.48; 95% CI 1.21-1.81, p=0.0001) and rivaroxaban (RR=1.38; 95% CI 1.03-1.83, p=0.04) associated with a higher risk of hospitalization or death from bleeding when compared to warfarin. The risk of hemorrhagic death was even larger with dabigatran (RR=1.78; 95% CI 1.18-2.68, p=0.006) and rivaroxaban (RR=1.71; 95% CI 0.94-3.12, p=0.07) relative to warfarin. There were too few events in the study to detect meaningful differences in stroke and arterial embolism between the drug groups.
Conclusions—More dialysis patients are being started on dabigatran and rivaroxaban, even when their use is contraindicated and there are no studies to support the benefits outweigh the risks of these drugs in ESRD.
- Received November 3, 2014.
- Revision received January 12, 2015.
- Accepted January 14, 2015.