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Wu HH, Chang SH, Lee TH, Tu HT, Liu CH, Chang TY. Concurrent use of statins decreases major bleeding and intracerebral hemorrhage in non-valvular atrial fibrillation patients taking direct oral anticoagulants—A nationwide cohort study. Front Cardiovasc Med 2022; 9:969259. [PMID: 36003918 PMCID: PMC9393418 DOI: 10.3389/fcvm.2022.969259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background Statins are frequently prescribed with direct oral anticoagulants (DOACs), and previous studies have raised concerns about the increased risk of intracerebral hemorrhage or other major bleeding in concurrent statins and DOACs use. The objective of this study is to evaluate the risk of major bleeding in non-valvular atrial fibrillation patients taking DOACs with or without statins. Methods This nationwide, retrospective cohort study used data from the Taiwan National Health Insurance Research Database, enrolled a total of 90,731 non-valvular atrial fibrillation patients receiving rivaroxaban, dabigatran, apixaban or edoxaban from January 1st, 2012 to December 31st, 2017. Major bleeding was defined as a hospitalization or emergency department visit with a primary diagnosis of intracerebral hemorrhage, gastrointestinal tract bleeding, urogenital tract bleeding, or other sites of bleeding. Adjusted incidence rate ratios (IRR) and differences of major bleeding between person-quarters of DOACs with or without statins were estimated using a Poisson regression and inverse probability of treatment weighting using the propensity score. Results 50,854 (56.0%) of them were male with a mean age of 74.9 (SD, 10.4) years. Using DOACs without statins as a reference, the adjusted IRR for all major bleedings in concurrent use of DOACs and statins was 0.8 (95% CI 0.72–0.81). Lower major bleeding risk was seen in both low-to-moderate-intensity statins (IRR: 0.8, 95% CI 0.74–0.84) and high-intensity statins (IRR: 0.8, 95% CI 0.74–0.88). Concurrent use of DOACs and statins decreased the risk for intracerebral hemorrhage with an IRR of 0.8 (95% CI 0.66–0.93), and gastrointestinal tract bleeding with an IRR of 0.7 (95% CI 0.69–0.79). The protective effect of statins on intracerebral hemorrhage was observed only in female patients (IRR 0.67, 95% CI 0.51–0.89), but not in male patients (IRR 0.87, 95% CI 0.70–1.08). Conclusions Among non-valvular atrial fibrillation patients who were taking DOACs, concurrent use of statins decreased major bleeding risk, including intracerebral hemorrhage and gastrointestinal tract bleeding. Considering this and other cardioprotective effects, statins should be considered in all eligible patients prescribed with DOACs.
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Affiliation(s)
- Hsin-Hsu Wu
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsong-Hai Lee
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neurology, Stroke Section, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Hung Liu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neurology, Stroke Section, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ting-Yu Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neurology, Stroke Section, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- *Correspondence: Ting-Yu Chang
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Bhagavathula AS, Vidyasaga K, Gebreyohannes EA, Tesfaye W. Risk of Gastrointestinal Bleeding on Treatment With Statin Alone or With Concomitant Administration of Warfarin: A Systematic Review and Meta-analysis of 5.3 Million Participants. Ann Pharmacother 2021; 56:820-830. [PMID: 34595940 DOI: 10.1177/10600280211049727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This study aimed to comprehensively evaluate the risk of gastrointestinal bleeding (GIB) with statin monotherapy or with concomitant warfarin use. DATA SOURCES PubMed, Web of Science, and EMBASE (via Scopus) were searched for observational studies that reported the risk of GIB in adults on statin therapy or with concomitant warfarin use until August 28, 2021. STUDY SELECTION AND DATA EXTRACTION Observational studies evaluating the risk of GIB in adults (age >18 years) on statin medication or concomitant use with warfarin were included. DATA SYNTHESIS In all, 14 studies with a total of 5 235 123 participants, reporting 48 677 GIB events (43 734 from statin users and 4943 from users of statin combined with warfarin), were included in the analyses. The pooled analysis revealed no difference in the risk of GIB with statin monotherapy (relative risk [RR]: 0.65; 95% CI: 0.42-1.02) or concomitant statin + warfarin use (RR: 0.97; 95% CI: 0.91-1.02). Prior use of statin was not associated with GIB risk (RR: 0.88; 95% CI: 0.63-1.22), whereas a shorter duration of statin use (<5 years) was associated with a lower risk of GIB (RR: 0.42; 95% CI: 0.18-0.97). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This analysis provides strong evidence on the association between statin use (with/without warfarin) and risk of GIB. CONCLUSION Statin alone or combined with warfarin was not significantly associated with either an increased or decreased risk of GIB. The GIB risk was significantly lower when statins were used for a short duration (<5 years). The putative relationship between statins and GIB in warfarin users warrant further investigation.
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Affiliation(s)
| | | | | | - Wubshet Tesfaye
- University of Canberra, Australian Capital Territory, Australia
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Wang M, Zeraatkar D, Obeda M, Lee M, Garcia C, Nguyen L, Agarwal A, Al-Shalabi F, Benipal H, Ahmad A, Abbas M, Vidug K, Holbrook A. Drug-drug Interactions with Warfarin: A Systematic Review and Meta-analysis. Br J Clin Pharmacol 2021; 87:4051-4100. [PMID: 33769581 DOI: 10.1111/bcp.14833] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 12/13/2022] Open
Abstract
AIM The objective of this paper is to systematically review the literature on drug-drug interactions with warfarin, with a focus on patient-important clinical outcomes. METHODS MEDLINE, EMBASE, and the International Pharmaceutical Abstract (IPA) databases were searched from January 2004 to August 2019. We included studies describing drug-drug interactions between warfarin and other drugs. Screening and data extraction were conducted independently and in duplicate. We synthesized pooled odds ratios (OR) with 95% confidence intervals (CIs), comparing warfarin plus another medication to warfarin alone. We assessed the risk of bias at the study level and evaluated the overall certainty of evidence using GRADE. RESULTS Of 42,013 citations identified, a total of 72 studies reporting on 3,735,775 patients were considered eligible, including 11 randomized clinical trials and 61 observational studies. Increased risk of clinically relevant bleeding when added to warfarin therapy was observed for antiplatelet (AP) regimens (OR=1.74; 95% CI 1.56, 1.94), many antimicrobials (OR=1.63; 95% CI 1.45, 1.83), NSAIDs including COX-2 NSAIDs (OR=1.83; 95% CI 1.29, 2.59), SSRIs (OR=1.62; 95% CI 1.42, 1.85), mirtazapine (OR=1.75; 95% CI 1.30, 2.36), loop diuretics (OR=1.92; 95% CI 1.29, 2.86), and others. We found a protective effect of proton pump inhibitors (PPIs) against warfarin-related gastrointestinal (GI) bleedings (OR=0.69; 95% CI 0.64, 0.73). No significant effect on thromboembolic events or mortality of any drug group used with warfarin was found, including single or dual AP regimens. CONCLUSIONS This review found low to moderate certainty evidence supporting the interaction between warfarin and a small group of medications, which result in increased bleeding risk. PPIs are associated with reduced hospitalization for upper GI bleeding for patients taking warfarin. Further studies are required to better understand drug-drug interactions leading to thromboembolic outcomes or death.
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Affiliation(s)
- Mei Wang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada.,Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Michael Obeda
- Department of Family Medicine, Queen's University, 220 Bagot St, Kingston, K7L 3G2, Ontario, Canada
| | - Munil Lee
- Schulich School of Medicine and Dentistry, Western University, London, N6A 3K7, Ontario, Canada
| | - Cristian Garcia
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Laura Nguyen
- Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, K1H 8M5, Ontario, Canada
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, 27 King's College Circle, Toronto, M5S 1A, Ontario, Canada
| | - Farah Al-Shalabi
- Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada
| | - Harsukh Benipal
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Afreen Ahmad
- Bachelor Health Sciences Program, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Momina Abbas
- Bachelor Arts & Science Program, Faculty of Arts & Science, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Kristina Vidug
- Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada.,Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada.,Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
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The Safety and Efficacy of Rivaroxaban Compared with Warfarin in Patients with Atrial Fibrillation and Diabetes: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2021; 21:51-61. [PMID: 32514866 DOI: 10.1007/s40256-020-00407-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIMS This meta-analysis was conducted to compare the efficacy and safety of rivaroxaban with warfarin in patients with atrial fibrillation (AF) and diabetes mellitus. METHODS PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched from the establishment of databases up to 15 October 2019. Studies on efficacy and safety outcomes of rivaroxaban and warfarin were included. Efficacy and safety outcomes, including stroke, ischemic stroke, stroke or systemic embolism, myocardial infarction, major adverse cardiac events, major bleeding, intracranial hemorrhage, and major gastrointestinal bleeding were collected for meta-analysis. RESULTS Compared with warfarin, rivaroxaban could significantly reduce stroke (risk ratio [RR] 0.77; 95% confidence interval [CI] 0.63-0.95; P = 0.01), ischemic stroke (RR 0.74; 95% CI 0.63-0.87; P = 0.0004), stroke or systemic embolism (RR 0.73; 95% CI 0.60-0.89; P = 0.002), myocardial infarction (RR 0.68; 95% CI 0.56-0.82; P < 0.0001), and major adverse cardiac events (RR 0.71; 95% CI 0.53-0.94; P = 0.02) in patients with AF and diabetes. Moreover, rivaroxaban was associated with a lower risk of major bleeding (RR 0.79; 95% CI 0.65-0.96; P = 0.02), intracranial hemorrhage (RR 0.52; 95% CI 0.39-0.69; P < 0.00001), and major gastrointestinal bleeding (RR 0.74; 95% CI 0.56-0.98; P = 0.04). Similar results were obtained in stratified meta-analysis of cohort studies. CONCLUSION Our study suggests a favorable risk-benefit profile of rivaroxaban, with superior efficacy and safety over warfarin in patients with AF and diabetes.
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Hauta-Aho M, Teperi S, Korhonen MJ, Bell JS, Farinola N, Johns S, Shakib S, Huupponen R. Frailty and Co-Prescribing of Potentially Interacting Drugs in New Users of Warfarin. Drugs Aging 2020; 37:373-382. [PMID: 32147805 PMCID: PMC7190596 DOI: 10.1007/s40266-020-00755-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Warfarin is underutilised in frail older people because of the fear of bleeding complications. Drug interactions are an independent bleeding risk factor. However, the extent to which potential drug interactions are taken into account at warfarin therapy initiation in frail patients is not known. Objective The objective of this study was to investigate the use of potentially interacting drugs increasing the bleeding risk before and after warfarin initiation in frail and non-frail patients. Methods We conducted an observational study including inpatients aged ≥ 60 years initiated on warfarin in a tertiary hospital in Adelaide, South Australia. Frailty status was assessed with the Reported Edmonton Frail Scale. Medication charts were reviewed before and after warfarin initiation. Results In total, 151 patients (102 non-frail and 49 frail) were included. Before warfarin initiation, the use of clopidogrel and acetaminophen was more common in frail patients compared with non-frail patients (25.5% vs 10.2%, p = 0.0135, 63.8% vs 35.7% p = 0.0014, respectively). The use of non-steroidal anti-inflammatory drugs, 9.2% in non-frail patients and 6.4% in frail patients before warfarin initiation, was completely stopped after warfarin initiation in both groups. The use of antiplatelet drugs decreased from 56.1% in non-frail patients and 66.0 % in frail patients to 12.2% and 14.9%, respectively. Instead, the use of drugs affecting the metabolism of warfarin or vitamin K increased in both groups. No statistically significant difference was seen in the exposure to interacting drugs between study groups after warfarin initiation. Acetaminophen, senna glycosides and cytochrome P450 2C9 inhibiting drugs were the most common interacting drugs at discharge used in 49.0%, 18.4% and 20.4% of non-frail patients and 53.2%, 29.8% and 19.1% of frail patients, respectively. Conclusions The overall frequency of potential drug interactions was moderate and frail patients were not exposed to warfarin drug interactions more often than non-frail patients. Further studies in larger study populations are required to verify these results. Electronic supplementary material The online version of this article (10.1007/s40266-020-00755-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Milka Hauta-Aho
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland. .,Clinical Pharmacology Unit, Turku University Hospital, Turku, Finland. .,Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Simo Teperi
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Maarit J Korhonen
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland.,Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
| | - J Simon Bell
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia.,NHMRC Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
| | - Nicholas Farinola
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sally Johns
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia.,Department of Clinical Pharmacology, Faculty of Health Science, University of Adelaide, Adelaide, SA, Australia
| | - Risto Huupponen
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland.,Clinical Pharmacology Unit, Turku University Hospital, Turku, Finland
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Ho B, Lin Y, Lin S, Chou P, Chen C, Lin R, Hu H, Chao A. Statins and the risk of bleeding in patients taking dabigatran. Acta Neurol Scand 2019; 139:455-461. [PMID: 30742307 DOI: 10.1111/ane.13077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/08/2019] [Accepted: 02/04/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Dabigatran etexilate is a direct thrombin inhibitor that clinicians increasingly prescribe to prevent stroke in patients with non-valvular atrial fibrillation (NVAF). Clinicians also commonly prescribe statins for primary and secondary prevention of cardiovascular diseases. Little is known about the bleeding risk in patients taking a statin and dabigatran together. The aim of this study was to evaluate the safety and persistence of dabigatran after co-medication with statins. MATERIALS AND METHODS We performed a prospective, multicenter registry study of stroke patients with NVAF who initiated dabigatran therapy within 3 months after a clinically evident ischemic cerebrovascular event between 2013 and 2017. The main outcome measure was symptomatic bleeding after 90, 180, and 360 days. RESULTS In total, 652 patients (336 statin users, 316 non-users) were followed for 1 year after dabigatran therapy. Cox multivariate analysis demonstrated that male sex, prior use of aspirin, and concurrent use of an antiarrhythmic drug were associated with a higher risk of bleeding at 360 days. After adjusting time-dependent covariates, statin users had a significantly lower bleeding risk (adjusted hazard ratio: 0.11, P < 0.001) than non-users. Kaplan-Meier analysis indicated that patients prescribed with statins had a higher rate of bleeding-free survival (P = 0.028). CONCLUSION For secondary prevention of stroke in patients with NVAF who are taking dabigatran etexilate, co-prescription with a statin was associated with a lower risk of bleeding complications. Future research is needed to determine the pharmacological mechanism underlying this effect.
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Affiliation(s)
- Bo‐Lin Ho
- Department of Neurology Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Neurology Kaohsiung Municipal Gangshan Hospital Kaohsiung Taiwan
| | - Ya‐Ju Lin
- Department of Neurology MacKay Memorial Hospital Taipei Taiwan
| | - Sheng‐Feng Lin
- School of Public Health, College of Public Health Taipei Medical University Taipei Taiwan
| | - Ping‐Song Chou
- Department of Neurology Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Neurology, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | - Chien‐Fu Chen
- Department of Neurology Kaohsiung Medical University Hospital Kaohsiung Taiwan
| | - Ruey‐Tay Lin
- Department of Neurology Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Neurology, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | - Han‐Hwa Hu
- Department of Neurology Taipei Medical University‐Shaung Ho Hospital Taipei Taiwan
- Graduate Institute of Clinical Medicine and Cerebrovascular Treatment and Research Center, College of Medicine Taipei Medical University Taipei Taiwan
| | - A‐Ching Chao
- Department of Neurology Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Neurology, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
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