Log in to MyACC
DOACs vs. Warfarin and Risk of Osteoporotic Fractures
Quick Takes
- Among patients with AF, DOAC use is associated with lower risk of osteoporotic fracture than warfarin use.
- Risk of osteoporotic fracture risk appears similar between different DOAC medications.
Study Questions:
What is the risk of osteoporotic fracture among patients with atrial fibrillation (AF) taking direct oral anticoagulants (DOAC) or warfarin?
Methods:
All patients with newly diagnosed AF between 2010 and 2017 who were prescribed either a DOAC or warfarin were followed through December 2018 using a regional registry of all public hospitals in Hong Kong. The primary outcome is osteoporotic hip and vertebral fractures. Propensity score-weighted cumulative incidence differences were calculated for each patient cohort pairs. Cox proportional hazard models were used to compare DOAC and warfarin use with fracture risk.
Results:
Among 23,515 patients with AF, warfarin was most commonly used (9,541 patients), followed by dabigatran (6,867), rivaroxaban (3,866), and apixaban (3,241). Mean age was 74.4 (standard deviation, 10.8) years. During a median follow-up of 423 days, 401 fractures were identified. Drug-specific rates of fracture ranged from 0.67 (rivaroxaban) to 1.11 (warfarin) per 100 patient-years. After 24 months of follow-up, DOAC use was associated with a lower risk for fracture than warfarin (cumulative incidence difference, -0.88% [apixaban]; -0.81% [dabigatran]; and -1.13% [rivaroxaban]). No significant difference between DOACs was identified. Each DOAC was associated with a significantly lower risk of fracture as compared to warfarin (hazard ratio, 0.62 [apixaban]; 0.65 [dabigatran]; 0.52 [rivaroxaban]).
Conclusions:
The authors concluded that among patients with AF, DOAC treatment is associated with a lower risk of osteoporotic fracture than warfarin use.
Perspective:
DOAC therapy is considered first-line for patients with nonvalvular AF for the prevention of stroke and systemic embolism. However, many patients wonder about the long-term safety of these “newer” drugs. One of the long-term risks associated with warfarin use is osteoporotic fracture (doi: 10.1001/archinte.166.2.241). This study confirms the findings from prior studies in Europe (doi: 10.1016/j.jacc.2019.08.1025) and the United States (doi: 10.1001/jamainternmed.2019.5679), but this time in an Asian population. While most patients with AF do not specifically ask about fracture risk when deciding on anticoagulant therapy, these data further support the role of DOACs as first-line therapy to prevent stroke and systemic embolism.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Embolism, Geriatrics, Hip Fractures, Osteoporotic Fractures, Risk, Secondary Prevention, Spinal Fractures, Stroke, Vascular Diseases, Warfarin
< Back to Listings
