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Álvaro Thomsen T, Mesa Guadalupe J, Huerta C, de Burgos A, Cea Soriano L. Risk of ischemic stroke associated with direct oral anticoagulants discontinuation on patients with non-valvular atrial fibrillation. Pharmacoepidemiol Drug Saf 2024; 33:e5733. [PMID: 38011912 DOI: 10.1002/pds.5733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 10/04/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Although direct oral anticoagulants' (DOACs) prescriptions have experienced immense growth in the last decade, the proportion of discontinuers is still common yielding an increased risk of ischemic stroke (IS) onset. AIMS We aimed to estimate the association between DOACs discontinuation and risk of IS among patients with non-valvular atrial fibrillation (NVAF). METHODS We used data from a cohort of new DOACs users, followed patients from the first DOAC prescription date up to IS (index date) and conducted a nested case-control analysis using conditional logistic regression. Adjusted odds ratios, 95% confidence intervals were calculated for discontinuation of DOACs (current use compared with past use). The latter, subdivided among those stopping treatment 3 to 2 months and 6 and 3 months prior to index date. The effect of naïve current users against IS onset compared with non-naïve current users was also evaluated. RESULTS DOACs discontinuation showed an OR of IS of 1.47 (95% CI: 1.02-2.12); estimates were 2.51 (95% CI: 1.84-3.42) for whom discontinued treatment within months 3 and 2 and 1.43 (95% CI: 0.96-2.13) for those between months 6 and 3 prior to index date. Analyzing DOACs individually, risk of IS associated with past users compared with current users: 1.98 (95% CI: 1.25-3.12) for apixaban, 1.38 (95% CI: 0.40-4.72) for edoxaban, 1.98 (95% CI: 1.24-2.65) for dabigatran and 1.87 (95% CI: 1.26-2.76) for rivaroxaban. Similar results were found when stratified by naïve and non-naïve users. CONCLUSIONS DOACs' discontinuation is associated with higher risk of IS, especially in the second and third months following interruption.
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Affiliation(s)
- T Álvaro Thomsen
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - J Mesa Guadalupe
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - C Huerta
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - A de Burgos
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
- BIFAP, Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - L Cea Soriano
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Willame C, Dodd C, Durán CE, Elbers RJHJ, Gini R, Bartolini C, Paoletti O, Wang L, Ehrenstein V, Kahlert J, Haug U, Schink T, Diez-Domingo J, Mira-Iglesias A, Carreras JJ, Vergara-Hernández C, Giaquinto C, Barbieri E, Stona L, Huerta C, Martín-Pérez M, García-Poza P, de Burgos A, Martínez-González M, Bryant V, Villalobos F, Pallejà-Millán M, Aragón M, Carreras JJ, Souverein P, Thurin NH, Weibel D, Klungel OH, Sturkenboom MCJM. Background rates of 41 adverse events of special interest for COVID-19 vaccines in 10 European healthcare databases - an ACCESS cohort study. Vaccine 2023; 41:251-262. [PMID: 36446653 PMCID: PMC9678835 DOI: 10.1016/j.vaccine.2022.11.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND In May 2020, the ACCESS (The vACCine covid-19 monitoring readinESS) project was launched to prepare real-world monitoring of COVID-19 vaccines. Within this project, this study aimed to generate background incidence rates of 41 adverse events of special interest (AESI) to contextualize potential safety signals detected following administration of COVID-19 vaccines. METHODS A dynamic cohort study was conducted using a distributed data network of 10 healthcare databases from 7 European countries (Italy, Spain, Denmark, The Netherlands, Germany, France and United Kingdom) over the period 2017 to 2020. A common protocol (EUPAS37273), common data model, and common analytics programs were applied for syntactic, semantic and analytical harmonization. Incidence rates (IR) for each AESI and each database were calculated by age and sex by dividing the number of incident cases by the total person-time at risk. Age-standardized rates were pooled using random effect models according to the provenance of the events. FINDINGS A total number of 63,456,074 individuals were included in the study, contributing to 211.7 million person-years. A clear age pattern was observed for most AESIs, rates also varied by provenance of disease diagnosis (primary care, specialist care). Thrombosis with thrombocytopenia rates were extremely low ranging from 0.06 to 4.53/100,000 person-years for cerebral venous sinus thrombosis (CVST) with thrombocytopenia (TP) and mixed venous and arterial thrombosis with TP, respectively. INTERPRETATION Given the nature of the AESIs and the setting (general practitioners or hospital-based databases or both), background rates from databases that show the highest level of completeness (primary care and specialist care) should be preferred, others can be used for sensitivity. The study was designed to ensure representativeness to the European population and generalizability of the background incidence rates. FUNDING The project has received support from the European Medicines Agency under the Framework service contract nr EMA/2018/28/PE.
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Affiliation(s)
- C Willame
- Department of Datascience & Biostatistics, University Medical Center Utrecht, Heidelberglaan 100, the Netherlands
| | - C Dodd
- Department of Datascience & Biostatistics, University Medical Center Utrecht, Heidelberglaan 100, the Netherlands
| | - CE Durán
- Department of Datascience & Biostatistics, University Medical Center Utrecht, Heidelberglaan 100, the Netherlands
| | - RJHJ Elbers
- Department of Data science & Biostatistic, Data manegement, University Medical Center Utrecht, Heidelberglaan 100, the Netherlands
| | - R Gini
- Agenzia regionale di sanità della Toscana, via Pietro Dazzi 1, 55100 Florence, Italy
| | - C Bartolini
- Agenzia regionale di sanità della Toscana, via Pietro Dazzi 1, 55100 Florence, Italy
| | - O Paoletti
- Agenzia regionale di sanità della Toscana, via Pietro Dazzi 1, 55100 Florence, Italy
| | - L Wang
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark
| | - V Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark
| | - J Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark
| | - U Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Faculty of Human and Health Sciences, University of Bremen, Germany
| | - T Schink
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, 28359 Bremen, Germany
| | - J Diez-Domingo
- Vaccine Research Department, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO – Public Health), Avenida Cataluña, 21, 46020 Valencia, Spain
| | - A Mira-Iglesias
- Vaccine Research Department, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO – Public Health), Avenida Cataluña, 21, 46020 Valencia, Spain
| | - JJ Carreras
- Vaccine Research Department, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO – Public Health), Avenida Cataluña, 21, 46020 Valencia, Spain
| | - C Vergara-Hernández
- Vaccine Research Department, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO – Public Health), Avenida Cataluña, 21, 46020 Valencia, Spain
| | - C Giaquinto
- Division of Paediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padova, Padova, Italy
| | - E Barbieri
- Division of Paediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padova, Padova, Italy
| | - L Stona
- Fondazione Penta ONLUS, Corso Stati Uniti 4, 35127 Padova, Italy
| | - C Huerta
- Department of Public Health and Maternal and Child Health, Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
| | - M Martín-Pérez
- Pharmacoepidemiology and Pharmacovigilance Division, Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Calle Campezo 1, 28022 Madrid, Spain
| | - P García-Poza
- Pharmacoepidemiology and Pharmacovigilance Division, Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Calle Campezo 1, 28022 Madrid, Spain
| | - A de Burgos
- Pharmacoepidemiology and Pharmacovigilance Division, Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Calle Campezo 1, 28022 Madrid, Spain
| | - M Martínez-González
- Pharmacoepidemiology and Pharmacovigilance Division, Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Calle Campezo 1, 28022 Madrid, Spain
| | - V Bryant
- Pharmacoepidemiology and Pharmacovigilance Division, Medicines for Human Use Department, Spanish Agency for Medicines and Medical Devices (AEMPS), Calle Campezo 1, 28022 Madrid, Spain
| | - F Villalobos
- Unitat de Suport a la Recerca Tarragona-Reus, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 43202 Reus, Spain
| | - M Pallejà-Millán
- Unitat de Suport a la Recerca Tarragona-Reus, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 43202 Reus, Spain
| | - M Aragón
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08007 Barcelona, Spain
| | - JJ Carreras
- Vaccine Research Department, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO – Public Health), Avenida Cataluña, 21, 46020 Valencia, Spain
| | - P Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, PO BOX 80082, 3508 TB Utrecht, the Netherlands
| | - NH Thurin
- INSERM CIC-P1401, Bordeaux PharmacoEpi, Univ. Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux cedex, France
| | - D Weibel
- Department of Datascience & Biostatistics, University Medical Center Utrecht, Heidelberglaan 100, the Netherlands
| | - OH Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, PO BOX 80082, 3508 TB Utrecht, the Netherlands
| | - MCJM Sturkenboom
- Department of Datascience & Biostatistics, University Medical Center Utrecht, Heidelberglaan 100, the Netherlands,Corresponding author at: Department Datascience & Biostatistics Univerisity Medical Center Utrecht, Heidelberglaan 100, The Netherlands
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