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Kidney Week

Abstract: SA-PO621

Increasing Use of Direct Oral Anticoagulants Among Hemodialysis Patients with Medicare Prescription Drug Coverage

Session Information

  • Pharmacology
    October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Hypertension and CVD

  • 1401 Hypertension and CVD: Epidemiology, Risk Factors, and Prevention


  • Weinhandl, Eric D., NxStage Medical, Inc., Victoria, Minnesota, United States
  • Ray, Debabrata, NxStage Medical, Inc., Victoria, Minnesota, United States
  • Kubisiak, Kristine, NxStage Medical, Inc., Victoria, Minnesota, United States
  • Collins, Allan J., NxStage Medical, Inc., Victoria, Minnesota, United States

For decades, warfarin was the only agent to be used for long-term anticoagulation. Since 2010, a series of direct oral anticoagulants (DOACs) have been approved by the United States Food and Drug Administration, including dabigatran, rivaroxaban, apixaban, edoxaban, and betrixaban. The efficacy and safety of DOACs in hemodialysis (HD) patients is poorly understood. We assessed trends in utilization of warfarin and DOACs among HD patients in 2011-2015.


We analyzed data from the United States Renal Data System. For each calendar month from January 2011 to December 2015, we identified patients who underwent HD and were enrolled in Medicare Part C or D; we also assessed whether HD was delivered in a facility or at home. From pharmacy claims, we identified whether each patient possessed a supply of warfarin, rivaroxaban, apixaban, or edoxaban. We estimated percentages of patients with a supply of any anticoagulant, any DOAC, and individual DOACs. We fit logistic generalized estimating equations of DOAC use, with adjustment for age, race, sex, primary cause of end-stage renal disease (ESRD), and dialytic setting.


Monthly sample sizes increased from roughly 249,000 in January 2011 to 311,000 in December 2015. During this era, the percentage of patients using any anticoagulant steadily increased from 9.2% to 10.2%. However, the percentage of patients using warfarin reached an apex of 9.4% in December 2013 and subsequently fell to less than 9.0% in late 2015. Concurrently, the percentage of patients using any DOAC increased from 0.1% to 1.3%. By December 2015, 11.6% of patients using an anticoagulant were DOAC users and 93.0% of patients using a DOAC were apixaban users. Among patient-months with anticoagulant use in 2015, positive predictors of DOAC use were older age and Asian (versus white) race; negative predictors were black (versus white) race and glomerulonephritis and polycystic kidney disease (versus diabetes) as the primary cause of ESRD. Relative to in-center hemodialysis, home hemodialysis was associated with 18% lower odds of DOAC use, but the association was not statistically significant (P = 0.09).


Among hemodialysis patients, warfarin use is decreasing, DOAC use is increasing, and apixaban dominates DOAC utilization. Direct comparisons of warfarin and apixaban are urgently needed.


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