Introduction: End-stage renal disease (ESRD) patients on dialysis with atrial fibrillation (AF) are at high risk for both thrombotic complications and treatment-associated bleeding. Although direct oral anticoagulants (DOACs) reduce these risks in other populations, their use in dialysis patients is not well characterized and is discouraged due to a lack of empirical data.
Hypothesis: We sought to characterize the utilization of DOACs in dialysis patients with AF requiring anticoagulation.
Methods: We identified eligible dialysis patients continuously enrolled in the comprehensive US Renal Data System database who were prescribed warfarin or a DOAC (new start or switch from warfarin) from October 2010 (following initial FDA approval) to December 2015. Patients with valvular heart disease were excluded.
Results: From a population of 1,313,637 patients with ESRD, 21,593 dialysis patients (female 48.5%, mean age 65.8 years) with a diagnosis of AF and a prescription for oral anticoagulation were identified. A total of 1,690 (7.8%) patients were prescribed DOACs (apixaban n=1,301, dabigatran n=201, rivaroxaban n=188; new start n=1,467, switch from warfarin=223), whereas 19,903 (92.2%) patients were prescribed warfarin only. DOACs were increasingly utilized relative to warfarin over the study period (p-for-trend <0.001; Figure), rising from 0.16% to 29.16%. Apixaban accounted for the majority of new DOAC prescriptions. Patients on DOACs and warfarin had comparable risk profiles, with similar age (mean 66.1 vs 65.7 years, p=0.23), prevalence of cerebrovascular disease (8.5% vs 9.0%, p=0.44), and CHA2DS2Vasc scores (mean 3.14 vs 3.18, p=0.28).
Conclusions: Overall use of DOACs in dialysis patients with AF is increasing rapidly and exceeded over one-quarter of prescriptions in 2015. This highlights the need for further study of these drugs in this complex population that is typically excluded from clinical trials.