Apixaban (Eliquis) is associated with reduced rates of ischemic stroke and bleeding in patients with atrial fibrillation and advanced chronic kidney disease compared with warfarin (Coumadin)

1. In patients with atrial fibrillation and advanced chronic kidney disease (CKD) not receiving dialysis, apixaban (Eliquis) was associated with significantly lower rates of bleeding and ischemic stroke compared to warfarin (Coumadin).

Evidence Rating Level: 2 (Good)

CKD is associated with an increased burden of cardiovascular complications, with studies showing a 12%-18% of AF in patients with CKD. Direct oral anticoagulants (DOACs) and warfarin are commonly used to prevent cardioembolic events in these patients. However, many of the initial pivotal trials excluded patients with CKD stage 4 or 5. Thus, it remains unclear how effective DOACs and warfarin are in this subgroup. This cohort study used patient data from 2 large United States health insurance claims databases and included patients with a diagnosis of CKD stage 4 or 5, a diagnosis of AF, CHA2DS2-VASc score of 2 or greater for men or 3 or greater for women, and have never required dialysis. 42 052 patients were identified, with 14 712 being new users of apixaban (mean [SD] age, 78.33 [7.26] years; 54.1% female), 6335 being new users of warfarin (mean [SD] age, 78.12 [7.05] years; 49.7% female), and 21 005 patients with no OAC use (mean [SD] age, 78.05 [7.49] years; 51.4% female). Compared with nonuse, apixaban was associated with a significantly higher rate of major bleeding (63.8 vs 47.5 per 1000 person-years (PY); HR, 1.32 [95% CI, 1.11 to 1.58]; RD, 17.16 [95% CI, 2.45 to 31.87] per 1000 PYs) and a significantly lower rate of ischemic stroke (9.4 vs 22.3 per 1000 PYs; HR, 0.46 [95% CI, 0.32 to 0.66]; RD, −12.67 [95% CI, −20.65 to −4.69] per 1000 PYs). Compared to nonuse, warfarin was associated with a significantly higher rate of major bleeding (116.2 vs 47.5 per 1000 PYs; HR, 2.44 [95% CI, 2.06 to 2.88]; RD, 70.20 [95% CI, 51.94 to 88.47] per 1000 PYs) and a nonsignificant decrease in rate of ischemic stroke (20.3 vs 22.3 per 1000 PYs; HR, 0.87 [95% CI, 0.61 to 1.22]; RD, −2.31 [−11.44 to 6.81] per 1000 PYs). Compared to warfarin, apixaban was associated with both a lower rate of major bleeding (HR, 0.55 [95% CI, 0.46 to 0.65]; RD, −53.30 [95% CI, −72.47 to −34.12] per 1000 PYs) and a lower rate of ischemic stroke (HR, 0.50 [95% CI, 0.33 to 0.78]; RD, −10.48 [95% CI, −18.37 to −2.59] per 1000 PYs). Both apixaban 5 mg twice daily and apixaban 2.5 mg twice daily were associated with lower rates of bleeding (standard dose: HR, 0.58 [95% CI, 0.45 to 0.75]; reduced dose: HR, 0.61 [95% CI, 0.50 to 0.75]) and ischemic stroke (standard dose: HR, 0.54 [95% CI, 0.30 to 0.98]; reduced dose: HR, 0.51 [95% CI, 0.31 to 0.84]) compared to warfarin.

Click here to read this study in JAMA Network Open

Image: PD

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