Safety of apixaban compared to warfarin in hemodialysis patients: Do antiplatelets make a difference?

Background Data on the safety of apixaban compared to warfarin in hemodialysis (HD) patients are accumulating, but the impact of concomitant antiplatelet use is unknown. Objectives Compare hemorrhagic risk and impact of antiplatelets in HD patients receiving oral anticoagulants (OAC). Methods Retrospective, multi-center study of HD patients started on OAC inpatient over 5 years. Results 707 patients were included: 563 received warfarin, and 144 received apixaban. 197 had bleeding, most in the warfarin group (173 [30.1%] vs 24 [16.7%] in the apixaban group), P-value < .01). However, with concomitant antiplatelet use, frequencies were similar (31.4% vs 25.0%; P-value = .292). Cumulative incidence using bleeding as event of interest and death as competing risk showed higher rates of bleeding with warfarin. In a multivariate model, apixaban was associated with a lower hemorrhagic risk (hazard ratio [HR] 0.55 [95% confidence interval {CI} 0.35-0.86}). Apixaban showed lower hemorrhagic risk alone (HR 0.24, 95% CI 0.10-0.55) and similar risk when administered with antiplatelets (HR 0.93, 95% CI 0.55-1.56). Conclusions Apixaban is associated with less bleeding in HD patients compared to warfarin, but concomitant antiplatelet use may negate the safety advantage. Prospective trials are warranted to determine the impact of antiplatelets on apixaban safety.

Automated summary

A study comparing the hemorrhagic risk in hemodialysis patients receiving oral anticoagulants found that apixaban is associated with lower bleeding risk compared to warfarin, but the safety advantage may be negated when antiplatelets are used concurrently. Prospective trials are needed to further investigate the impact of antiplatelet use on apixaban safety.