Background

Studies have shown that patients with non-valvular atrial fibrillation (NVAF) who discontinue oral anticoagulants (OACs) are at higher risk of complications such as stroke.

Objective

This analysis compared the risk of non-persistence with OACs among patients with NVAF.

Methods

Adult patients with NVAF who initiated apixaban, dabigatran, rivaroxaban, or warfarin were identified using 01JAN2013–30JUN2019 data from Centers for Medicare and Medicaid Services and four US commercial claims databases. Non-persistence was defined as discontinuation (no evidence of index OAC use for ≥ 60 days from the last days’ supply) or switch to another OAC. Kaplan–Meier curves were generated to illustrate time to non-persistence along with cumulative incidences of non-persistence. Baseline and time-varying covariates were evaluated, and adjusted Cox proportional hazards models were used to evaluate non-persistence risk.

Results

In total, 363,823 patients receiving apixaban, 57,121 receiving dabigatran, 282,831 receiving rivaroxaban, and 317,337 receiving warfarin were included. Of these, 47–72% discontinued/switched OAC therapy within an average 9-month follow-up. Apixaban was associated with a lower risk of non-persistence than were dabigatran (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.61–0.62), rivaroxaban (HR 0.76; 95% CI 0.75–0.76), and warfarin (HR 0.74; 95% CI 0.74–0.75). Dabigatran was associated with a higher risk of non-persistence than were warfarin (HR 1.21; 95% CI 1.19–1.22) and rivaroxaban (HR 1.23; 95% CI 1.22–1.25), and rivaroxaban was associated with a lower risk of non-persistence than was warfarin (HR 0.98; 95% CI 0.97–0.98). Clinical events (stroke/systemic embolism and major bleeding [MB]) during follow-up were predictors of non-persistence (stroke HR 1.57; 95% CI 1.53–1.61; MB HR 2.96; 95% CI 2.92–3.00).

Conclusion

In over one million patients with NVAF, our results suggest differences in anticoagulation treatment persistence across OAC agents, even after accounting for clinical events after OAC initiation. It is important for clinicians and patients to take these differences into consideration, especially as non-persistence to OAC therapy is associated with thromboembolic complications.

中文翻译：

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美国非瓣膜性房颤患者不坚持口服抗凝治疗

背景

研究表明，停用口服抗凝剂（OAC）的非瓣膜性心房颤动（NVAF）患者发生中风等并发症的风险较高。

客观的

该分析比较了 NVAF 患者不坚持使用 OAC 的风险。

方法

使用来自医疗保险和医疗补助服务中心以及四个美国商业索赔数据库的 2013 年 1 月 1 日至 2019 年 6 月 30 日的数据确定了开始使用阿哌沙班、达比加群、利伐沙班或华法林的成年 NVAF 患者。不坚持被定义为停药（没有证据表明索引 OAC 自最后几天的供应以来使用了 ≥ 60 天）或改用另一种 OAC。生成卡普兰-迈耶曲线来说明非持久性的时间以及非持久性的累积发生率。评估基线和时变协变量，并使用调整后的 Cox 比例风险模型来评估非持续性风险。

结果

总共纳入了 363,823 名接受阿哌沙班治疗的患者、57,121 名接受达比加群治疗的患者、282,831 名接受利伐沙班治疗的患者和 317,337 名接受华法林治疗的患者。其中，47-72% 的人在平均 9 个月的随访期内停止/转用 OAC 治疗。与达比加群（风险比 [HR] 0.62；95% 置信区间 [CI] 0.61–0.62）、利伐沙班（HR 0.76；95% CI 0.75–0.76）和华法林（ HR 0.74；95% CI 0.74–0.75）。与华法林（HR 1.21；95% CI 1.19–1.22）和利伐沙班（HR 1.23；95% CI 1.22–1.25）相比，达比加群与较高的非持续性风险相关，而利伐沙班与较低的非持续性风险相关。其持久性优于华法林（HR 0.98；95% CI 0.97–0.98）。随访期间的临床事件（卒中/全身性栓塞和大出血 [MB]）是非持续性的预测因素（卒中 HR 1.57；95% CI 1.53–1.61；MB HR 2.96；95% CI 2.92–3.00）。

结论

在超过 100 万 NVAF 患者中，我们的结果表明，即使考虑了 OAC 启动后的临床事件，不同 OAC 药物的抗凝治疗持续性也存在差异。对于临床医生和患者来说，考虑这些差异非常重要，特别是因为不坚持 OAC 治疗与血栓栓塞并发症相关。