Fracture in Association with Anticoagulant Therapy in Patients with Chronic Kidney Disease and Atrial Fibrillation

. Methods: We conducted a new user, active comparator cohort study in a United States-based commercial claims database spanning 2013 through 2020 to quantify the comparative risk of fracture associated with select DOACs (apixaban or rivaroxaban) versus warfarin. Individuals were required to have International Classification of Diseases diagnosis codes for CKD (stages 3-5) and atrial fibrillation during the 365-day baseline period before anticoagulant initiation. Primary analyses quantified non-vertebral fracture risk between patients initiating DOACs and warfarin using a 1:1 propensity score-matched design. Cox proportional hazards regression was used to obtain hazard ratios (HRs) and 95% confidence intervals (CIs) of non-vertebral fracture. Secondary analyses evaluated risks of hip fracture and all-cause mortality. Results: The 1:1 propensity score-matched population included 14,370 DOAC initiators and 14,370 warfarin initiators. The mean age at anticoagulant initiation was 77 years, and 45% were female. The HR for non-vertebral fracture comparing DOACs to warfarin was 1.12 (95% CI 0.95, 1.32), and the corresponding incidence rate difference (IRD) per 1,000 person-years was 3.55 (95% CI -1.67, 8.76). The HR and IRD comparing DOACs to warfarin were 0.98 (95% CI 0.68, 1.41) and -0.13 (95% CI, -2.52, 2.25), respectively for hip fracture and 0.91 (95% CI 0.85, 0.98) and -17.23 (95% CI, -29.49, -4.96), respectively for all-cause mortality. Conclusions: In patients with CKD and atrial fibrillation, we did not observe a difference in the rates of fracture between DOAC and warfarin initiators. DOAC use relative to warfarin was associated with a lower risk of all-cause mortality. Copyright © 2024 by the American Society of Nephrology...