Afib: DOACs tied to reduced fracture risk vs warfarin

  • Lutsey PL & al.
  • JAMA Intern Med
  • 25/11/2019

  • Emily Willingham, PhD
  • Clinical Essentials
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Takeaway

  • For patients with Afib, direct oral anticoagulants (DOACs), especially apixaban (Eliquis), are linked to lower fracture risk vs warfarin.
  • Comparative effectiveness study finds reduced risk vs warfarin except for hip fracture.

Why this matters

  • Warfarin potentially is an adverse risk factor for bone health.

Key results

  • New users of DOACs vs new users of warfarin had lower risk (adjusted HRs, 95% CIs) for:
    • Fracture requiring hospitalization: 0.87 (0.79-0.96).
    • Any clinical fracture: 0.93 (0.88-0.98).
    • But not significantly lower risk for hip fractures: 0.91 (0.78-1.07).
  • Among the DOACs, apixaban was tied to the lowest risk for all comparisons (adjusted HRs, 95% CIs) vs warfarin:
    • Fracture requiring hospitalization: 0.60 (0.47-0.78).
    • Any clinical fracture: 0.86 (0.75-0.98).
    • Hip fracture: 0.67 (0.45-0.98).
  • Some hints in subgroup analyses that patients with existing osteoporosis gained greater fracture-related benefit from DOACs (HR, 0.74; 95% CI, 0.58-0.96) vs those without osteoporosis (HR, 1.06; 95% CI, 0.86-1.30).

Study design

  • MarketScan data analyzed for 167,275 patients with Afib (38.0% women; mean age, 68.9 years) and taking a DOAC (18.9% dabigatran [Pradaxa]; 21.1% rivaroxaban [Xarelto]; 10.6% apixaban) or using warfarin (49.4%).
  • Funding: NIH; others.

Limitations

  • Residual confounding possible.
  • The DOAC edoxaban (Savaysa) was not included because of too few users.