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Type of Oral Anticoagulant and Adverse Clinical Outcomes
Quick Takes
- Use of apixaban was associated with lower rates of recurrent VTE than warfarin when used after the initial 90-day period.
- There was no significant difference in the rate of recurrent VTE between apixaban and rivaroxaban use after the initial 90-day period.
- Use of apixaban, rivaroxaban, and warfarin was associated with similar rates of hospitalization for bleeding for extended VTE treatment.
Study Questions:
What is the risk of recurrent venous thromboembolism (VTE) and major bleeding for patients treated with apixaban, rivaroxaban, or warfarin after an initial 90-day course of anticoagulation for VTE?
Methods:
The authors combined data from Medicare (2009-2017) and two commercial health insurance databases (2004-2018) to identify 64,642 adults who initiated oral anticoagulation following hospital discharge for VTE and continued treatment beyond 90 days. The primary outcome was recurrent VTE and hospitalization for major bleeding. Analyses were adjusted using propensity-score weighting based on receipt of apixaban, rivaroxaban, or warfarin after the initial 90-day treatment period.
Results:
The study included 9,167 patients prescribed apixaban, 12,468 prescribed rivaroxaban, and 43,007 prescribed warfarin. The median follow-up was 109 days (interquartile range [IQR], 59-228) for recurrent VTE and 108 days (IQR, 58-226) for major bleeding. Weighted incidence rates of hospitalization for recurrent VTE were lower for patients receiving apixaban versus warfarin (9.8 vs. 13.5 per 1,000 person-years; hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.49-0.99) but not different between apixaban and rivaroxaban (HR, 0.80; 95% CI, 0.53-1.19) or between rivaroxaban and warfarin (HR, 0.87; 95% CI, 0.65-1.16). Rates of hospitalization for major bleeding were 44.4 per 1,000 person-years for apixaban, 50.0 per 1,000 person-years for rivaroxaban, and 47.1 per 1,000 person-years for warfarin. None of these were significantly different from one another.
Conclusions:
The authors concluded that patients prescribed extended-duration oral anticoagulation after hospitalization for VTE experienced lower rates of recurrent VTE when they received apixaban as compared to warfarin after the initial 90-day window. The authors also concluded that there was no difference in the rate of hospitalization for bleeding among any of the compared anticoagulants used after the initial 90-day window.
Perspective:
While all patients with acute VTE are recommended to receive a minimum 90-day course of anticoagulation, many benefit from longer-courses of anticoagulation to prevent recurrent VTE. This large study provides three key findings. First, there were no differences in rates of hospitalization for bleeding and small to no differences in the rate of recurrent VTE between apixaban, rivaroxaban, and warfarin. Second, the rate of recurrent VTE was quite low in all three treatment groups, confirming their high degree of efficacy. Third, the rate of hospitalization for bleeding was markedly higher than the rate of recurrent VTE. As such, careful consideration of bleeding and recurrent VTE risk is appropriate before determining if extended anticoagulation is appropriate for patients with VTE. However, interpretation of the study results should be done with caution since details on apixaban and rivaroxaban dose were not available for the analysis.
Clinical Topics: Anticoagulation Management, Geriatric Cardiology, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism
Keywords: Anticoagulants, Geriatrics, Hemorrhage, Patient Discharge, Rivaroxaban, Secondary Prevention, Vascular Diseases, Venous Thromboembolism, Warfarin
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