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Outcomes associated with apixaban use in end-stage kidney disease patients with atrial fibrillation in the United States

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Show simple item record Konstantinos, Siontis C. Zhang, Xiaosong Eckard, Ashley Bhave, Nicole Schaubel, Douglas E. He, Kevin Tilea, Anca Stack, Austin G. Balkrishnan, Rajesh Yao, Xiaoxi Noseworthy, Peter A. Shah, Nilay D. Saran, Rajiv Nallamothu, Brahmajee K. 2019-10-31T09:19:47Z 2019-10-31T09:19:47Z 2018
dc.identifier.issn 0009-7322
dc.description peer-reviewed en_US
dc.description.abstract Background: Patients with end-stage kidney disease (ESKD) on dialysis were excluded from clinical trials of direct oral anticoagulants for atrial fibrillation (AF). Recent data have raised concerns regarding the safety of dabigatran and rivaroxaban, but apixaban has not been evaluated despite current labeling supporting its use in this population. The goal of this study was to determine patterns of apixaban use and its associated outcomes in dialysis-dependent patients with ESKD and AF. Methods: We performed a retrospective cohort study of Medicare beneficiaries included in the United States Renal Data System (October 2010 to December 2015). Eligible patients were those with ESKD and AF undergoing dialysis who initiated treatment with an oral anticoagulant. Because of the small number of dabigatran and rivaroxaban users, outcomes were only assessed in patients treated with apixaban or warfarin. Apixaban and warfarin patients were matched (1:3) based on prognostic score. Differences between groups in survival free of stroke or systemic embolism, major bleeding, gastrointestinal bleeding, intracranial bleeding, and death were assessed using Kaplan–Meier analyses. Hazard ratios (HRs) and 95% CIs were derived from Cox regression analyses. Results: The study population consisted of 25 523 patients (45.7% women; 68.2±11.9 years of age), including 2351 patients on apixaban and 23 172 patients on warfarin. An annual increase in apixaban prescriptions was observed after its marketing approval at the end of 2012, such that 26.6% of new anticoagulant prescriptions in 2015 were for apixaban. In matched cohorts, there was no difference in the risks of stroke/systemic embolism between apixaban and warfarin (HR, 0.88; 95% CI, 0.69–1.12; P=0.29), but apixaban was associated with a significantly lower risk of major bleeding (HR, 0.72; 95% CI, 0.59–0.87; P<0.001). In sensitivity analyses, standard-dose apixaban (5 mg twice a day; n=1034) was associated with significantly lower risks of stroke/systemic embolism and death as compared with either reduced-dose apixaban (2.5 mg twice a day; n=1317; HR, 0.61; 95% CI, 0.37–0.98; P=0.04 for stroke/systemic embolism; HR, 0.64; 95% CI, 0.45–0.92; P=0.01 for death) or warfarin (HR, 0.64; 95% CI, 0.42–0.97; P=0.04 for stroke/systemic embolism; HR, 0.63; 95% CI, 0.46–0.85; P=0.003 for death). Conclusions: Among patients with ESKD and AF on dialysis, apixaban use may be associated with a lower risk of major bleeding compared with warfarin, with a standard 5 mg twice a day dose also associated with reductions in thromboembolic and mortality risk. en_US
dc.language.iso eng en_US
dc.publisher Lippincott, Williams & Wilkins en_US
dc.relation.ispartofseries Circulation;138, pp. 1519-1529
dc.rights This is the author's version of "title of article" published in Circulation, 2018, 38, pp.1519-1529 © 2018 Lippincott, Williams and Wilkins. The final published version can be found at en_US
dc.subject atrial fibrillation en_US
dc.subject anticoagulation en_US
dc.subject dialysis en_US
dc.subject stroke prevention en_US
dc.subject bleeding en_US
dc.title Outcomes associated with apixaban use in end-stage kidney disease patients with atrial fibrillation in the United States en_US
dc.type info:eu-repo/semantics/article en_US
dc.type.supercollection all_ul_research en_US
dc.type.supercollection ul_published_reviewed en_US 2019-10-31T09:08:48Z
dc.identifier.doi 10.1161/CIRCULATIONAHA.118.035418
dc.contributor.sponsor National Institute of Digestive and Diabetes and Kidney Diseases (NIDDK) en_US
dc.relation.projectid HHSN276201400001C en_US
dc.rights.accessrights info:eu-repo/semantics/openAccess en_US
dc.internal.rssid 2869587
dc.internal.copyrightchecked Yes
dc.identifier.journaltitle Circulation
dc.description.status peer-reviewed

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