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Drugs & Aging

, Volume 35, Issue 12, pp 1089–1098 | Cite as

Dabigatran Versus Rivaroxaban for Secondary Stroke Prevention in Patients with Atrial Fibrillation Rehabilitated in Skilled Nursing Facilities

  • Matthew AlcuskyEmail author
  • Anne L. Hume
  • Marc Fisher
  • Jennifer Tjia
  • Robert J. Goldberg
  • David D. McManus
  • Kate L. Lapane
Short Communication

Abstract

Background

Thromboembolic and bleeding risk are elevated in older patients with atrial fibrillation and prior stroke. We compared dabigatran with rivaroxaban for secondary prevention in a national population after skilled nursing facility (SNF) discharge.

Methods

Medicare fee-for-service beneficiaries aged ≥ 65 years with atrial fibrillation hospitalized for ischemic stroke (November 2011–October 2013) and subsequently admitted to an SNF were studied. Dabigatran (n = 332) and rivaroxaban users (n = 378) were compared in a retrospective, active comparator, new-user cohort. The index medication claim occurred within 120 days after hospital discharge and exposure continued until a 14-day treatment gap (‘as treated’). The primary net clinical benefit outcome was the time to recurrent stroke, transient ischemic attack, intracranial hemorrhage, extracranial bleed, myocardial infarction, venous thromboembolism, or death. All-cause mortality was evaluated separately as a secondary outcome. Multivariable adjusted Cox models stratified by dosage estimated hazard ratios (aHR).

Results

Among those receiving low dosages, the crude composite event rate was 40.4/100 person-years among dabigatran users and 33.7/100 person-years among rivaroxaban users. The composite outcome [aHR 1.48; 95% confidence interval (CI) 0.87–2.51] and all-cause mortality (aHR 1.67; 95% CI 0.84–3.31) rates were higher among low-dose dabigatran users. For those receiving standard doses, the crude composite event rates were 19.5/100 person-years for dabigatran users and 37.1/100 person-years for rivaroxaban users. Although no difference in mortality was observed, the composite outcome rate was lower among standard-dose dabigatran users (aHR 0.65; 95% CI 0.36–1.15).

Conclusions

In older adults treated with direct-acting oral anticoagulants after ischemic stroke, outcome rates varied considerably by drug and dosage.

Notes

Compliance with Ethical Standards

The University of Massachusetts Medical School Institutional Review Board approved this study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of research formal consent is not required.

Funding

At the time the study was conducted, Dr Alcusky was funded by the National Center for Advancing Translational Sciences (TL1TR001454). Dr McManus was funded by the National Heart, Lung, and Blood Institute (RO1HL126911, RO1HL135219, RO1HL136660, R15HL121761). Partial support for Dr Goldberg was provided by the National Heart, Lung, and Blood Institute (1R01HL126911-01A1, 5R01HL125089-02, 5R01HL115295-05).

Conflict of interest

Dr. Tjia is a consultant for CVS Health. Dr. Alcusky, Dr. Goldberg, Dr. Fisher, Dr. Lapane, and Dr. Hume have no interests to disclose.

Supplementary material

40266_2018_610_MOESM1_ESM.docx (35 kb)
Supplementary material 1 (DOCX 34 kb)

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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Matthew Alcusky
    • 1
    Email author
  • Anne L. Hume
    • 2
  • Marc Fisher
    • 3
  • Jennifer Tjia
    • 1
  • Robert J. Goldberg
    • 1
  • David D. McManus
    • 1
    • 4
  • Kate L. Lapane
    • 1
  1. 1.Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterUSA
  2. 2.Department of Pharmacy Practice, College of PharmacyUniversity of Rhode IslandKingstonUSA
  3. 3.Department of Neurology, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  4. 4.Division of Cardiovascular Medicine, Department of MedicineUniversity of Massachusetts Medical SchoolWorcesterUSA

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