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.