Labaf et al. Thrombosis Journal 2014, 12:29 http://www.thrombosisjournal.com/content/12/1/29
ORIGINAL CLINICAL INVESTIGATION
Open Access
Efficacy and safety of novel oral anticoagulants in clinical practice: a report from three centers in Sweden Ashkan Labaf1,2*†, Martin Carlwe3† and Peter J Svensson1,4
Abstract Introduction: In clinical trials new oral anticoagulants (NOAC) have proved to be as effective as warfarin for thromboprophylaxis in atrial fibrillation. The aim of this study was to evaluate the efficacy and safety of these drugs in clinical practise. Methods and results: All patients treated with new oral anticoagulants at Skåne University hospital and Halland County Hospital Halmstad between 2009 and September 2013 was identified in the Swedish national quality registry for atrial fibrillation and anticoagulation (AuriculA). Medical records were reviewed to identify thromboembolism and major bleeding and compared to a warfarin cohort with a time in therapeutic range (TTR) of 76%. There were 826 patients, mean age 70.6, follow up 591 years, with atrial fibrillation treated with NOAC. Dabigatran was the initial drug in 79% of the cohort. The incidences of ischemic stroke/ TIA and major bleeding were 1.9 (95% CI; 1.0-3.2) and 2.0 (95% CI; 1.1-3.5) per 100 patient-years respectively. The corresponding incidences for warfarin were 1.5 (95% CI; 1.0-2.2) and 2.5 (95% CI; 1.8-3.3), with no statistical significance between the groups. Two subdural hematomas occurred 0.4 (95% CI; 0.06-1.1) per 100 patient-years. Mean age of patients with complications was 77.9 (±5.9) and 69.3 (±11.3) for those without (p < 0.001). The discontinuation rate was 6.5% and 1.7% was due to dyspepsia for dabigatran, lower than the RE-LY trial. Conclusion: This study, largely based on dabigatran shows that treatment is efficient and safe in everyday clinical practice and not significantly different compared to a warfarin cohort with tight anticoagulation control. Keywords: Novel oral anticoagulants, Dabigatran, Atrial fibrillation, Thromboembolism, Major bleeding
Background Oral anticoagulation with warfarin is an effective treatment for prevention of ischemic stroke and systemic thromboembolism in atrial fibrillation (AF). However, the need of regular INR checks and significant interaction with diet and drugs are detrimental. These concerns have dramatically been modified with the introduction of the novel oral anticoagulants (NOACs) – dabigatran, a factor IIa (thrombin) inhibitor, and the factor Xa inhibitors rivaroxaban and apixaban [1-3]. The pharmacokinetics of these preparations is predictable, which means that frequent samplings similar to those that are necessary during * Correspondence: [email protected] † Equal contributors 1 Department of Clinical Sciences, Lund University, Malmö, Sweden 2 Department of Cardiology, Skåne University Hospital, Malmö, Sweden Full list of author information is available at the end of the article
treatment with warfarin are redundant. RE-LY (Randomized Evaluation of Long-Term Anticoagulant therapy) compared two doses of dabigatran etexilate against warfarin in AF patients with 1 or more stroke risk factors. The 150 mg b.i.d. was superior for the primary efficacy endpoint with similar a similar rate of bleeding whereas the 110 mg b.i.d. dose was noninferior to warfarin for the primary endpoint and superior to warfarin for major bleeding events. ROCKET AF (Rivaroxaban versus Warfarin in Non valvular atrial fibrillation) compared rivaroxaban once daily against warfarin and reported noninferiority for efficacy and safety. The Danish registry study on dabigatran, showed that the results for dabigatran appear to persist even in everyday clinical practice [4]. However, this study used registers searching diagnoses according to The International Classification of Diseases (ICD) for extraction of data, including
© 2014 Labaf et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Labaf et al. Thrombosis Journal 2014, 12:29 http://www.thrombosisjournal.com/content/12/1/29
patient-related risk factors. All of the drugs have a degree of renal excretion, especially dabigatran which is why The European Society of Cardiology recommends that renal function should be monitored during treatment with NOAC [5]. Reduced glomerular filtration rate (GFR) with NOACs is associated with bleeding events [6]. The main purpose of this study was to evaluate the efficacy and safety of treatment with NOAC in three Swedish centers and compared with a historical cohort treated with warfarin. As a secondary objective, we assessed predictors of adverse events by a case control study.
Material and methods All patients treated with NOAC at Halland County Hospital Halmstad, Skåne University hospital in Lund and Malmö between 2009 and September 2013 was identified in the Swedish national quality registry for atrial fibrillation and anticoagulation (AuriculA). AuriculA was introduced in 2008 at our centres and now contains over 110,000 patients with more than 200 affiliated centers managing their daily dosing activity of oral anticoagulants, mainly warfarin, through the system. The program is web-based and includes decision support for dosing of warfarin. This methodology ensures that all patients treated with NOAC at these centres are included, thus reducing potential selection bias. All medical records and AuriculA were reviewed to obtain data on sex, indication for anticoagulation treatment, treatment time, complications and mortality. This cohort was compared to a historical cohort of patients from the same centres with warfarin from 2008, also by means of AuriculA [7]. The primary outcome were ischemic stroke, transient ischemic attack (TIA), systemic embolism, acute myocardial infarction (AMI) and major bleeding. AMI was defined as type 1 MI [8]. The International Society on thrombosis and Haemostasis definition on major bleeding was used (fatal bleeding, and/or symptomatic bleeding in a critical area of organ, such as intracranial or pericardial or intramuscular with compartment syndrome, and/or bleeding causes a fall in haemoglobin level of 20 g/L or more, or leading to transfusion of two or more units of red cells [9]. A case control study was performed to identify risk factors including kidney function, CHADS2, CHA2DS2-VASc and HAS-BLED for ischaemic stroke/TIA and major bleeding among patients with atrial fibrillation treated with a NOAC. The case group was defined as those who suffered of stroke/TIA or major bleeding event. The control group was defined as patients with NOAC treatment without an adverse event and was matched by age, sex and type of medication. For every case, three subjects were randomly selected as controls. Eleven cases with stroke/ TIA were matched with 33 controls, and 12 cases with major bleeding were matched with 36 controls.
Page 2 of 5
From the medical records, data on plasma creatinine, CHA2DS2-VASc and HAS-BLED were obtained for the case control group. Estimated-GFR (eGFR) was calculated by the Lund-Malmö equation [10]. The protocol was based on renal monitoring at treatment initiation, after 3, 6 and 12 months of treatment and thereafter annually except in subjects with reduced renal function who were monitored biannually. Statistical analysis
Categorical data were described by percentages and compared using the chi-square test, and Student’s t-test was used for continuous data. The days at risk were extracted from AuriculA for each patient and Incidence rates were calculated using the Person time module in Openepi, version 3.01 (www.openepi.com) with 95% confidence intervals. Multivariate logistic regression analysis was used to identify risk factors associated with thrombosis and major bleeding in the case control study. The control group were matched by age and gender and type of medication (Dabigatran and Rivaroxaban). All tests were performed two-tailed, and a p-value
ORIGINAL CLINICAL INVESTIGATION
Open Access
Efficacy and safety of novel oral anticoagulants in clinical practice: a report from three centers in Sweden Ashkan Labaf1,2*†, Martin Carlwe3† and Peter J Svensson1,4
Abstract Introduction: In clinical trials new oral anticoagulants (NOAC) have proved to be as effective as warfarin for thromboprophylaxis in atrial fibrillation. The aim of this study was to evaluate the efficacy and safety of these drugs in clinical practise. Methods and results: All patients treated with new oral anticoagulants at Skåne University hospital and Halland County Hospital Halmstad between 2009 and September 2013 was identified in the Swedish national quality registry for atrial fibrillation and anticoagulation (AuriculA). Medical records were reviewed to identify thromboembolism and major bleeding and compared to a warfarin cohort with a time in therapeutic range (TTR) of 76%. There were 826 patients, mean age 70.6, follow up 591 years, with atrial fibrillation treated with NOAC. Dabigatran was the initial drug in 79% of the cohort. The incidences of ischemic stroke/ TIA and major bleeding were 1.9 (95% CI; 1.0-3.2) and 2.0 (95% CI; 1.1-3.5) per 100 patient-years respectively. The corresponding incidences for warfarin were 1.5 (95% CI; 1.0-2.2) and 2.5 (95% CI; 1.8-3.3), with no statistical significance between the groups. Two subdural hematomas occurred 0.4 (95% CI; 0.06-1.1) per 100 patient-years. Mean age of patients with complications was 77.9 (±5.9) and 69.3 (±11.3) for those without (p < 0.001). The discontinuation rate was 6.5% and 1.7% was due to dyspepsia for dabigatran, lower than the RE-LY trial. Conclusion: This study, largely based on dabigatran shows that treatment is efficient and safe in everyday clinical practice and not significantly different compared to a warfarin cohort with tight anticoagulation control. Keywords: Novel oral anticoagulants, Dabigatran, Atrial fibrillation, Thromboembolism, Major bleeding
Background Oral anticoagulation with warfarin is an effective treatment for prevention of ischemic stroke and systemic thromboembolism in atrial fibrillation (AF). However, the need of regular INR checks and significant interaction with diet and drugs are detrimental. These concerns have dramatically been modified with the introduction of the novel oral anticoagulants (NOACs) – dabigatran, a factor IIa (thrombin) inhibitor, and the factor Xa inhibitors rivaroxaban and apixaban [1-3]. The pharmacokinetics of these preparations is predictable, which means that frequent samplings similar to those that are necessary during * Correspondence: [email protected] † Equal contributors 1 Department of Clinical Sciences, Lund University, Malmö, Sweden 2 Department of Cardiology, Skåne University Hospital, Malmö, Sweden Full list of author information is available at the end of the article
treatment with warfarin are redundant. RE-LY (Randomized Evaluation of Long-Term Anticoagulant therapy) compared two doses of dabigatran etexilate against warfarin in AF patients with 1 or more stroke risk factors. The 150 mg b.i.d. was superior for the primary efficacy endpoint with similar a similar rate of bleeding whereas the 110 mg b.i.d. dose was noninferior to warfarin for the primary endpoint and superior to warfarin for major bleeding events. ROCKET AF (Rivaroxaban versus Warfarin in Non valvular atrial fibrillation) compared rivaroxaban once daily against warfarin and reported noninferiority for efficacy and safety. The Danish registry study on dabigatran, showed that the results for dabigatran appear to persist even in everyday clinical practice [4]. However, this study used registers searching diagnoses according to The International Classification of Diseases (ICD) for extraction of data, including
© 2014 Labaf et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Labaf et al. Thrombosis Journal 2014, 12:29 http://www.thrombosisjournal.com/content/12/1/29
patient-related risk factors. All of the drugs have a degree of renal excretion, especially dabigatran which is why The European Society of Cardiology recommends that renal function should be monitored during treatment with NOAC [5]. Reduced glomerular filtration rate (GFR) with NOACs is associated with bleeding events [6]. The main purpose of this study was to evaluate the efficacy and safety of treatment with NOAC in three Swedish centers and compared with a historical cohort treated with warfarin. As a secondary objective, we assessed predictors of adverse events by a case control study.
Material and methods All patients treated with NOAC at Halland County Hospital Halmstad, Skåne University hospital in Lund and Malmö between 2009 and September 2013 was identified in the Swedish national quality registry for atrial fibrillation and anticoagulation (AuriculA). AuriculA was introduced in 2008 at our centres and now contains over 110,000 patients with more than 200 affiliated centers managing their daily dosing activity of oral anticoagulants, mainly warfarin, through the system. The program is web-based and includes decision support for dosing of warfarin. This methodology ensures that all patients treated with NOAC at these centres are included, thus reducing potential selection bias. All medical records and AuriculA were reviewed to obtain data on sex, indication for anticoagulation treatment, treatment time, complications and mortality. This cohort was compared to a historical cohort of patients from the same centres with warfarin from 2008, also by means of AuriculA [7]. The primary outcome were ischemic stroke, transient ischemic attack (TIA), systemic embolism, acute myocardial infarction (AMI) and major bleeding. AMI was defined as type 1 MI [8]. The International Society on thrombosis and Haemostasis definition on major bleeding was used (fatal bleeding, and/or symptomatic bleeding in a critical area of organ, such as intracranial or pericardial or intramuscular with compartment syndrome, and/or bleeding causes a fall in haemoglobin level of 20 g/L or more, or leading to transfusion of two or more units of red cells [9]. A case control study was performed to identify risk factors including kidney function, CHADS2, CHA2DS2-VASc and HAS-BLED for ischaemic stroke/TIA and major bleeding among patients with atrial fibrillation treated with a NOAC. The case group was defined as those who suffered of stroke/TIA or major bleeding event. The control group was defined as patients with NOAC treatment without an adverse event and was matched by age, sex and type of medication. For every case, three subjects were randomly selected as controls. Eleven cases with stroke/ TIA were matched with 33 controls, and 12 cases with major bleeding were matched with 36 controls.
Page 2 of 5
From the medical records, data on plasma creatinine, CHA2DS2-VASc and HAS-BLED were obtained for the case control group. Estimated-GFR (eGFR) was calculated by the Lund-Malmö equation [10]. The protocol was based on renal monitoring at treatment initiation, after 3, 6 and 12 months of treatment and thereafter annually except in subjects with reduced renal function who were monitored biannually. Statistical analysis
Categorical data were described by percentages and compared using the chi-square test, and Student’s t-test was used for continuous data. The days at risk were extracted from AuriculA for each patient and Incidence rates were calculated using the Person time module in Openepi, version 3.01 (www.openepi.com) with 95% confidence intervals. Multivariate logistic regression analysis was used to identify risk factors associated with thrombosis and major bleeding in the case control study. The control group were matched by age and gender and type of medication (Dabigatran and Rivaroxaban). All tests were performed two-tailed, and a p-value
