Extended treatment of DOAC results in less hospitalizations for recurrent VTE
Association of Type of Oral Anticoagulant Dispensed With Adverse Clinical Outcomes in Patients Extending Anticoagulation Therapy Beyond 90 Days After Hospitalization for Venous Thromboembolism
Introduction and methods
VTE has a substantial morbidity and mortality, and warfarin has long been the only oral anticoagulant to manage VTE [1,2]. Nowadays , though, 4 direct oral anticoagulants (DOACs) are widely used. Extended treatment (> 90 days) has been assessed in various studies, but there has been no direct comparison of DOACs with warfarin or against each other [3-7].
Aim of the study
This study compared extended prescription dispenses for the two DOACs apixaban and rivaroxaban, and warfarin for the outcomes of hospitalization for VTE recurrence, hospitalization for major bleeding events, and mortality.
This was an exploratory retrospective cohort study including 64,642 adults who initiated oral anticoagulation following hospitalization discharge for VTE and continued treatment beyond 90 days. Data were derived from three health claims databases in the US. Of the included patients, 9,167 patients had apixaban, 12,468 patients had rivaroxaban, and 43,007 patients had warfarin. For recurrent VTE, median follow-up was 109 (IQR: 59-228 ) days. For major bleeding, median follow-up was 108 (IQR: 58-226) days. Propensity score matching weights were used to correct for non-random allocation of patients to treatment groups.
The primary outcome of the study was hospitalization for recurrent VTE and hospitalization for major bleeding. Secondary outcome was all-cause mortality.
- Apixaban had a significantly lower incidence rate of hospitalization for recurrent VTE was when compared with warfarin (9.8 vs 13.5 per 1000 person-years; HR, 0.69, 95%CI:0.49-0.99).No significant different incidence rates of hospitalization for recurrent VTE between patients with apixaban and rivaroxaban (9.8 vs 11.6 per 1000 person-years; HR 0.80, 95%CI: 0.53-1.19) or rivaroxaban and warfarin (11.6 vs. 13.5 per 1000 person-years, HR 0.87, 95%CI: 0.65-1.16) were observed.
- Rates of hospitalization for major bleeding were 44.4 per 1000 person-years for apixaban, 50.0 per 1000 person-years for rivaroxaban, and 47.1 per 1000 person-years for warfarin; this results in HRs of 0.92 (95%CI: 0.78-1.09) for apixaban vs warfarin, 0.86 (95%CI: 0.71-1.04) for apixaban vs rivaroxaban, and 1.07 (95%CI: 0.93-1.24) for rivaroxaban vs warfarin.
- Rates of death were not different between the 3 groups.
In patients who filled prescriptions for extended therapy with oral anticoagulants after hospitalization for VTE, prescription dispenses for apixaban > 90 days in comparison with warfarin > 90 days, were significantly associated with a modestly lower rate of hospitalization for recurrent VTE. There was no significant difference in rate of hospitalization for major bleeding or all-cause mortality when comparing patients prescribed apixaban with patients prescribed warfarin.