Apixaban may be superior vs. other anticoagulants for older patients with AF, dementia
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Key takeaways:
- Apixaban tied to less stroke and bleeding in patients with/without dementia vs. dabigatran, rivaroxaban or warfarin.
- This association was strongest for the outcome of major bleeding.
Among older patients with atrial fibrillation and dementia, apixaban was associated with lower risk for stroke and major bleeding vs. dabigatran, rivaroxaban or warfarin, researchers reported.
The association was also detected in patients with AF but no dementia, but to a lesser degree.
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“The prescribing decisions for oral anticoagulants need to be individualized according to comorbidities and frailty because the risk-benefit profiles of oral anticoagulants can vary substantially in different risk groups. The presence of dementia often complicates such a decision because persons living with dementia are at higher risk of falls, traumatic intracranial bleeding, medication errors and low adherence to treatment regimens,” Kueiyu Joshua Lin, MD, ScD, MPH, assistant professor of medicine in the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women’s Hospital, and colleagues wrote in JAMA Network Open. “We aimed to examine the comparative safety and effectiveness of specific oral anticoagulants by assessing the risks of ischemic stroke and major bleeding events by dementia status among older patients with AF.”
To compare the efficacy and safety of apixaban (Eliquis, Bristol Myers Squibb/Pfizer), dabigatran (Pradaxa, Boehringer Ingelheim), rivaroxaban (Xarelto, Janssen/Bayer) and warfarin by dementia status among patients aged 65 years or older with AF, researchers conducted the present retrospective comparative effectiveness study of 1.16 million 1:1 matched patients (mean age, 77.4 years; 50.2% men; 80.5% white).
Patient data were collected using the Optum Clinformatics Data Mart, IBM MarketScan research database and Medicare claims databases.
The primary endpoint was a composite of ischemic stroke or major bleeding events during the 6-month period after oral anticoagulant initiation.
Overall, 7.9% of the cohort had dementia.
Comparing oral anticoagulants
Three comparative cohorts were established:
- warfarin compared with apixaban (n = 501,990; mean age, 78.1 years; 50.2% women);
- dabigatran compared with apixaban (n = 126,718; mean age, 76.5 years; 48% women); and
- rivaroxaban compared with apixaban (n = 531,754; mean age, 76.9 years; 49.9% women).
Among patients with dementia, researchers observed a higher rate of the primary composite endpoint among patients prescribed warfarin (adjusted HR = 1.5; 95% CI, 1.3-1.7), dabigatran (aHR = 1.5; 95% CI, 1.2-2) and rivaroxaban (aHR = 1.3; 95% CI, 1.1-1.5) compared with apixaban.
In all three comparative cohorts, the association between lower risk for the primary endpoint among apixaban users was similar regardless of dementia diagnosis; however, the rate difference differed.
For warfarin compared with apixaban users, Lin and colleagues observed an adjusted rate difference of 29.8 events per 1,000 person-years in patients with dementia compared with 16 events per 1,000 person-years in patients without dementia.
For dabigatran compared with apixaban users, researchers observed an adjusted rate difference of 29.6 events per 1,000 person-years in patients with dementia compared with 5.8 events per 1,000 person-years in patients without dementia.
For rivaroxaban compared with apixaban users, researchers observed an adjusted rate difference of 20.5 events per 1,000 person-years in patients with dementia compared with 15.9 events per 1,000 person-years in patients without dementia.
Moreover, the association between apixaban and lower risk for the composite primary outcome among patients with dementia was strongest for the outcome of major bleeding, according to the study.
Study supports use of apixaban
“Our results among persons living with dementia have provided important data about this vulnerable population of patients who have been substantially underrepresented in clinical trials. The association of oral anticoagulants with significantly higher risks of major bleeding and ischemic stroke on the rate difference scale was proportional to the absolute event rates across dementia subgroups,” the researchers wrote. “Despite a substantially higher baseline rate of all outcomes among persons living with dementia, apixaban use was associated with a similar relative rate reduction regardless of dementia diagnosis, yielding a substantially higher absolute rate reduction compared with the other oral anticoagulants. The fact that the absolute net clinical benefits associated with apixaban in comparison with other oral anticoagulants were greater among persons living with dementia than those without dementia supports the use of apixaban in highly vulnerable patients with frailty.”
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