Apixaban vs. Warfarin in Atrial Fibrillation Patients With Chronic Kidney Disease

Abstract

Background and Objectives: Real-world evidence of apixaban treatment in patients with chronic kidney disease remains scarce. This study aimed to compare the relative risk of stroke or systemic embolism (SE) and major bleeding between apixaban and warfarin in atrial fibrillation (AF) patients with different degrees of kidney function.Design, Setting, Participants, and Measurements: We evaluated newly diagnosed AF patients between 2004 and 2018, who were receiving apixaban or warfarin. Electronic medical record data were collected from a large healthcare delivery network in Taiwan. The outcomes of hospitalization for stroke/SE and major bleeding were compared with propensity-score matched apixaban and warfarin cohorts. Stratified analyses according to initial apixaban dose (standard dose of 10 mg/day vs. lower dose of 2.5–5.0 mg/day) and baseline estimated glomerular filtration rate were performed.Results: Each cohort involved 1,625 matched patients. Apixaban was significantly associated with a lower risk of stroke/SE (adjusted hazard ratio [aHR]: 0.74; 95% confidence interval [CI]:0.57–0.97; p = 0.03). The risk of major bleeding was not increased whether in standard doses (aHR: 0.66; 95% CI: 0.45–0.96; p = 0.03) or reduced doses (aHR, 0.84; 95% CI, 0.63–1.12; p = 0.23) of apixaban. Regarding kidney function, apixaban reduced the risk of stroke/SE by 37% in those with an eGFR of <30 ml/min/1.73 m2 (aHR: 0.63; 95% CI: 0.40–0.98; p = 0.04).Conclusions: Compared to warfarin, apixaban is associated with a reduced risk of stroke/SE and is consistent with a subset of AF patients with eGFR <30 ml/min/1.73 m2. Both standard and reduced doses of apixaban showed lower risk of major bleeding than those of warfarin.

Comparison of the Efficacy and Safety of Apixaban and Warfarin in the Prevention of Stroke in Patients With Non-valvular Atrial Fibrillation: A Meta-Analysis

“…Characteristics of the eligible studies are presented in Table 1. Among all the included studies, only one article was a randomized control trial [12] while other studies were either observational cohorts [16][17][18]20] or retrospective cohorts [14][15]19,21]. One study was published in 2011 [12] while other studies were published between 2016 and 2021 [14][15][16][17][18][19][20][21].…”

“…Among all the included studies, only one article was a randomized control trial [12] while other studies were either observational cohorts [16][17][18]20] or retrospective cohorts [14][15]19,21]. One study was published in 2011 [12] while other studies were published between 2016 and 2021 [14][15][16][17][18][19][20][21]. One study included patients in which only a reduced dose (2.5 mg) of apixaban was given [19] while the majority of studies included patients in which patients taking both reduced (2.5 mg) and standard (5 mg) of apixaban [12,[14][15][17][18].…”

“…One study was published in 2011 [12] while other studies were published between 2016 and 2021 [14][15][16][17][18][19][20][21]. One study included patients in which only a reduced dose (2.5 mg) of apixaban was given [19] while the majority of studies included patients in which patients taking both reduced (2.5 mg) and standard (5 mg) of apixaban [12,[14][15][17][18].…”

“…No significant publication bias was found in the primary efficacy endpoint and secondary efficacy endpoint, for comparison between warfarin and apixaban as a p-value of the Egger regression test was >0.05. All the included articles reported the primary efficacy outcome [12,[14][15][16][17][18][19][20][21], including 267998 patients with available data in terms of stroke or systemic embolism. The risk of stroke or systemic embolism is 23% lower in patients receiving apixaban as compared to patients receiving warfarin (RR: 0.77, 95% CI: 0.67-0.90).…”

“…All the included studies reported primary safety outcomes, i.e. major bleeding, including 267998 patients with atrial fibrillation [12,[14][15][16][17][18][19][20][21]. The administration of apixaban was associated with a significant reduction in major bleeding events compared with warfarin (RR=0.63, 95% CI: 0.58-0.68).…”