Comparative effectiveness of novel oral anticoagulants in UK patients with non-valvular atrial fibrillation and chronic kidney disease: a matched cohort study

• Published in: BMJ open 2018-01, Vol.8 (1), p.e019638-e019638
• Main Authors: Loo, Simone Y, Coulombe, Janie, Dell’Aniello, Sophie, Brophy, James M, Suissa, Samy, Renoux, Christel
• Format: Article
• Language: English
• Subjects: Administration, Oral; Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Anticoagulants - administration & dosage; Anticoagulants - adverse effects; Atrial Fibrillation - drug therapy; Atrial Fibrillation - mortality; Cardiac arrhythmia; Cohort analysis; Cohort Studies; Comorbidity; Epidemiology; Female; Gastrointestinal Hemorrhage - chemically induced; Gastrointestinal Hemorrhage - epidemiology; Humans; Kidney diseases; Male; Middle Aged; Mortality; Primary Health Care - organization & administration; Regression Analysis; Renal Insufficiency, Chronic - complications; Risk Factors; Stroke; Stroke - epidemiology; Stroke - etiology; United Kingdom - epidemiology; Vitamin K - antagonists & inhibitors; Young Adult
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2017-019638

ObjectivesTo evaluate the effectiveness and safety of novel oral anticoagulants (NOACs) compared with vitamin K antagonists (VKAs) among patients with non-valvular atrial fibrillation (NVAF), particularly those with chronic kidney disease (CKD).DesignPopulation-based matched cohort study.SettingOver 670 primary care practices in the UK, contributing to the Clinical Practice Research Datalink.ParticipantsUp to 6818 adult patients newly treated with NOACs between 2011 and 2016, matched 1:1 to new users of VKAs on age, sex and high-dimensional propensity score.InterventionsCurrent exposure to NOACs compared with current exposure to VKAs.Main outcome measuresHRs of ischaemic stroke and systemic embolism (SE), major bleeding, gastrointestinal (GI) bleeding, intracranial bleeding, myocardial infarction and all-cause mortality.ResultsIn as-treated analyses, the rates of ischaemic stroke/SE were similar between NOACs and VKAs (HR 0.94; 95% CI 0.62 to 1.42), as were the rates of major bleeding (HR 0.86; 95% CI 0.56 to 1.33). NOACs also significantly increased the risk of GI bleeding (HR 1.78; 95% CI 1.27 to 2.48). In patients with NVAF and CKD, NOACs and VKAs remained comparable with respect to the risk of ischaemic stroke/SE (HR 0.79; 95% CI 0.40 to 1.58) and major bleeding (HR 0.88; 95% CI 0.47 to 1.62), with no difference in the risk of GI bleeding (HR 0.99; 95% CI 0.63 to 1.55). Similar results were obtained in on-treatment analyses using a time-dependent exposure definition.ConclusionsOur results suggest that in the UK primary care, NOACs are overall effective and safe alternatives to VKAs, among patients with NVAF altogether, as well as in patients with NVAF and CKD.