Presentation Details
| Rivaroxaban in Older Adults with Nonvalvular Atrial Fibrillation: Population-based Analysis in Response to Updated Beers Criteria Ghadeer Dawwas1, Adam Cuker2. 1Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.2Department of Medicine, Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA |
Abstract
BACKGROUND Concerns have been raised regarding the updated Beers Criteria that recommended avoiding rivaroxaban use for long-term treatment of older adults with nonvalvular atrial fibrillation. We sought to compare the effectiveness and safety of rivaroxaban with other oral anticoagulants in elderly patients with nonvalvular atrial fibrillation. METHODS This was a retrospective new-user cohort study using MarketScan IBM commercial healthcare data in the United States from 1 January 2013 to 31 December 2021. We included patients 65 years or older at cohort entry, who had 12 months of continuous enrollment in medical and pharmacy benefits prior to their first eligible prescription and a diagnosis of atrial fibrillation prior to treatment initiation. We created three pairwise comparisons: a) rivaroxaban vs. warfarin; b) rivaroxaban vs. dabigatran; and c) rivaroxaban vs. apixaban. Our primary effectiveness outcome was a composite of ischemic stroke or systemic embolism defined using the principal position code of the International Classification of Diseases, Ninth and Tenth Revision. Our primary safety outcome was a composite of gastrointestinal or intracranial bleeding defined based on primary inpatient discharge diagnosis codes. Patients in the cohort were followed until the earliest of treatment discontinuation, switch to the comparator drug, outcome, last day of enrollment in health care benefits, or end of the study period. To adjust for potential baseline differences, we calculated propensity scores using logistic regression. Cox proportional hazards regression with a robust variance estimator was used to estimate hazard ratios [HRs] and 95% confidence intervals [CIs]. RESULTS We identified 70,678 patients who had received a prescription for rivaroxaban or warfarin (35,399 for each, comparison 1). In the matched sample, there was no difference between users of rivaroxaban and warfarin in the risk of stroke or systemic embolism (HR 0.89; 95% CI 0.79, 1.01) and bleeding (HR 1.07; 95% CI 0.98, 1.16). We identified 26,910 patients who had received a prescription for rivaroxaban or dabigatran (13,445 each, comparison 2). In the matched sample, there was no difference between users of rivaroxaban and dabigatran in the risk of stroke or systemic embolism (HR 0.92; 95% CI 0.80, 1.06). However, use of rivaroxaban was associated with a higher risk of bleeding compared with dabigatran (HR 1.20; 95% CI 1.06, 1.36). We identified 55,118 patients who had received a prescription for rivaroxaban or apixaban (27,559 each, comparison 3). In the matched sample, use of rivaroxaban compared with apixaban was associated with a higher risk of stroke or systemic embolism (HR 1.32; 95% CI 1.15, 1.52) and bleeding (HR 1.63; 95% CI 1.47, 1.80). CONCLUSION In this comparative effectiveness and safety study, older patients with nonvalvular atrial fibrillation who were new users of rivaroxaban had a higher risk of stroke or systemic embolism when compared with apixaban and bleeding when compared with apixaban or dabigatran. Although our results did not show potential benefits for rivaroxaban over other oral anticoagulants, the atrial fibrillation population is heterogeneous, and certain subgroups may potentially benefit from rivaroxaban.
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