Key result
Older AF patients with CKD initiate apixaban at ~18% higher rates than those without.
Why the study?
Data were lacking on anticoagulant initiation patterns among older atrial fibrillation patients with and without chronic kidney disease.
What are the temporal trends in anticoagulant initiation among older adults with atrial fibrillation with and without chronic kidney disease?
Cohort (n=60,322)
Yes
What are the temporal trends in anticoagulant initiation among older adults with atrial fibrillation with and without chronic kidney disease?
DOACs, particularly apixaban, have largely replaced warfarin for incident atrial fibrillation in older adults regardless of CKD status, with an increasing trend toward standard dosing even in CKD.
Apixaban preference among older AF patients with CKD should not yet change practice; leaves open randomized outcome data by CKD stage.
BACKGROUND: There is a paucity of data on the initiation patterns of anticoagulants among older atrial fibrillation patients with and without chronic kidney disease (CKD). SETTING AND METHODS: We used the UK Clinical Practice Research Datalink (2010-2020) to conduct a retrospective cohort study to evaluate anticoagulant initiation patterns for older adults (≥65 years) with CKD (N=18 421) and without CKD (N=41 901), categorised by severity of CKD: stages 3a, 3b and 4, and initiation dose by respective direct oral anticoagulant (DOAC). RESULTS: Over the study period, warfarin initiations sharply declined and were replaced by DOACs regardless of CKD status or stage. By 2020, patients with CKD were modestly more likely (8.8% difference) to initiate apixaban compared with those without CKD (58.8% vs 50.0%; p<0.01). Among patients with CKD, those with stages 3a and 3b CKD had higher apixaban initiations compared with stage 4 CKD (56.9% and 64.6% vs 52.9%, respectively; p<0.01). Conversely, patients with stage 4 CKD were over three times more likely to initiate warfarin (14.7%) compared with those with stage 3a (2.6%) and 3b (4.0%) CKD (p<0.01). Throughout the study period, there was a rise in the proportion of patients initiating the higher 10 mg daily dose for apixaban, with an increase of 20.6% (from 64.3% in 2013 to 84.9% in 2020; p value for trend <0.01) among patients without CKD, and 21.8% (53.1% to 74.9%; p<0.01), 24.4% (18.8% to 43.2%; p<0.01) and 18.5% (0.0% to 18.2%; p<0.01) among patients with stages 3a, 3b and 4 CKD, respectively. CONCLUSIONS AND RELEVANCE: Initiation of DOACs increased regardless of CKD status and stage, although with a reduced magnitude in severe CKD. Apixaban emerged as the preferred agent, with a secular trend towards the higher initiation dose in all subgroups. These findings illuminate evolving trends and priorities in anticoagulant preferences among patients with and without CKD.
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Liaw et al. (2024) conducted a cohort in Atrial fibrillation (n=60,322). Anticoagulants vs. Without chronic kidney disease was evaluated on Apixaban initiation by 2020 (p=<0.01). By 2020, older atrial fibrillation patients with chronic kidney disease were more likely to initiate apixaban compared with those without CKD (58.8% vs 50.0%; p<0.01).
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