title: Bleeding rates in Veterans Affairs patients with atrial fibrillation who switch from warfarin to dabigatran.
abstract: OBJECTIVE
  Clinical trial data suggest that dabigatran and warfarin have similar rates of major bleeding but higher rates of gastrointestinal bleeding. These findings have not been evaluated outside of a clinical trial. We evaluated the relative risks of any, gastrointestinal, intracranial, and other bleeding for Veterans Affairs patients who switched to dabigatran after at least 6 months on warfarin, compared with patients who continued on warfarin.
  
  
  METHODS
  We used national Veterans Affairs administrative encounter and pharmacy data from fiscal years 2010-2012 to identify 85,344 patients with atrial fibrillation who had been taking warfarin for at least 180 days before June 2011, of whom 1394 (1.7%) received dabigatran (150 mg) during the next 15 months. Dates of the first occurrence of each type of bleed and dates of death from June 2011 to September 2012 were determined. Baseline and time-dependent patient characteristics were identified, including comorbid conditions, stroke and bleeding risk scores, and time in therapeutic range for international normalized ratios. Marginal structural models were used to address selection bias in the longitudinal observational data. Weighted logistic regression models were fit using generalized estimating equations and reflected baseline and time-dependent covariates and weekly indicators of anticoagulant type (warfarin or dabigatran).
  
  
  RESULTS
  Compared with patients who never used dabigatran, patients who used dabigatran at least once were younger, were more likely to be white, had lower international normalized ratio time in therapeutic range on warfarin, had lower stroke risk scores, and had similar bleeding risk scores. Overall, 10,734 patients experienced bleeding events, including 131 events after dabigatran use. The risk-adjusted rate of any bleeding was higher with dabigatran compared with warfarin, which was largely driven by a 54% higher risk of gastrointestinal bleeding with dabigatran. Rates of intracranial, other bleeding, and death were similar for dabigatran and warfarin.
  
  
  CONCLUSIONS
  Dabigatran may increase the likelihood of gastrointestinal bleeds.
authors.affiliation: Comprehensive Access and Delivery Research and Evaluation Center (CADRE), Iowa City VA Medical Center, Iowa City; Department of Internal Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa, Iowa City. Electronic address: mary-vaughan-sarrazin@uiowa.edu.
authors.forename: Mary S
authors.initials: MS
authors.lastname: Vaughan Sarrazin
authors.affiliation: Comprehensive Access and Delivery Research and Evaluation Center (CADRE), Iowa City VA Medical Center, Iowa City; Department of Biostatistics, College of Public Health, University of Iowa, Iowa City.
authors.forename: Michael
authors.initials: M
authors.lastname: Jones
authors.affiliation: Department of Internal Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa, Iowa City.
authors.forename: Alexander
authors.initials: A
authors.lastname: Mazur
authors.affiliation: Department of Epidemiology, College of Public Health, University of Iowa, Iowa City.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Chrischilles
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ont., Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Cram
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D000991:Antithrombins / Q000009:adverse effects*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D001562:Benzimidazoles / Q000009:adverse effects*; D015331:Cohort Studies; D000069604:Dabigatran; D057915:Drug Substitution; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced*; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D019934:International Normalized Ratio; D020300:Intracranial Hemorrhages / Q000139:chemically induced*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D014481:United States; D014493:United States Department of Veterans Affairs; D014859:Warfarin / Q000627:therapeutic use; D015091:beta-Alanine / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D000925:Anticoagulants; D000991:Antithrombins; D001562:Benzimidazoles; D015091:beta-Alanine; D014859:Warfarin; D000069604:Dabigatran
keywords: Anticoagulation; Antithrombotic; Atrial fibrillation; Stroke
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