(P-625) Utilization and Long-term Persistence of Direct Oral Anticoagulants Among Patients with Non-valvular Atrial Fibrillation and Liver Disease

Background: Direct oral anticoagulants (DOACs) are recommended as first-line treatment for the prevention of ischemic stroke among patients with non-valvular atrial fibrillation (NVAF). However, the use of DOACs among patients with NVAF and underlying liver disease, a high-risk population with an increased propensity for both thrombosis and bleeding, remains poorly understood.

Objectives: To characterize the utilization and long-term treatment persistence of DOACs among patients with NVAF and liver disease in routine clinical practice.

Methods: Using the United Kingdom’s Clinical Practice Research Datalink AURUM, we assembled a population-based cohort of patients with NVAF and liver disease who initiated treatment with DOACs or the therapeutic alternative vitamin K antagonists (VKAs) between January 2011 and January 2020. Logistic regression estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the associations between patient characteristics and initiation of DOACs versus VKAs. Cox proportional hazards models estimated adjusted hazard ratios (HRs) and 95% CIs of the associations between patient characteristics and switch from VKAs to DOACs versus remaining on VKAs. We also assessed the 5-year treatment persistence with DOACs versus VKAs. All analyses were repeated among NVAF patients with cirrhosis, a severe form of liver disease, to explore the potential impact of liver disease severity on DOAC utilization and persistence.

Results: Our study cohort included 3,167 patients with NVAF and liver disease who initiated DOACs (n = 2,247; 71%) or VKAs (n = 920; 29%). Initiators of DOACs (1,231 apixaban, 121 dabigatran, 137 edoxaban, 758 rivaroxaban) were more likely to have prior ischemic stroke (OR, 1.44; 95% CI, 1.12 to 1.85) and to have used selective serotonin reuptake inhibitors (OR, 1.50; 95% CI, 1.09 to 2.04) than initiators of VKAs, but they were less likely to have used antiplatelet agents (OR, 0.66; 95% CI, 0.53 to 0.82). Patients switching to DOACs were more likely to have used selective serotonin reuptake inhibitors (HR, 1.64; 95% CI, 1.13 to 2.37) than those remaining on VKAs. At 5 years, 31% of DOAC initiators and 9% of VKA initiators remained persistent. The analyses remained consistent among NVAF patients with cirrhosis.

Conclusions: Most patients with NVAF and liver disease initiated treatment with DOACs. Long-term persistence with DOACs was higher than with VKAs but remained relatively low.