Article Impact Level: HIGH Data Quality: STRONG Summary of JAMA, 331(18), 1565. https://doi.org/10.1001/jama.2024.3867 Dr. Wayne A. Ray et al.
Points
- The study aimed to compare the risk of severe bleeding events in atrial fibrillation patients on anticoagulants (apixaban or rivaroxaban) who were treated with either diltiazem or metoprolol.
- The study included 204,155 US Medicare beneficiaries aged 65 or older, of whom 53,275 received diltiazem and 150,880 received metoprolol.
- Patients on diltiazem had a higher risk of bleeding-related hospitalization and death compared to those on metoprolol (Rate Difference [RD] 10.6 per 1000 person-years; Hazard Ratio [HR] 1.21).
- Higher initial doses of diltiazem (>120 mg/day) were linked to an even greater risk of severe bleeding events (RD 15.1 per 1000 person-years; HR 1.29) compared to lower doses (RD 6.7 per 1000 person-years; HR 1.13).
- The findings highlight the need to consider potential drug interactions and dose effects when prescribing diltiazem to patients on anticoagulants, suggesting the importance of individualized treatment strategies to reduce adverse events.
Summary
Diltiazem, a commonly prescribed medication for ventricular rate control in atrial fibrillation patients, has been linked to potential interactions with anticoagulants like apixaban and rivaroxaban, leading to concerns of over-anticoagulation. This retrospective cohort study aimed to compare the risk of severe bleeding events in new users of apixaban or rivaroxaban with atrial fibrillation who were treated with diltiazem or metoprolol.
The study included 204,155 US Medicare beneficiaries aged 65 years or older, with 53,275 receiving diltiazem and 150,880 receiving metoprolol. Patients on diltiazem exhibited an increased risk of the primary outcome (bleeding-related hospitalization and death with recent bleeding evidence) compared to those on metoprolol (Rate Difference [RD] 10.6 per 1000 person-years; Hazard Ratio [HR] 1.21). Notably, patients on higher initial doses of diltiazem (>120 mg/d) had a greater risk of severe bleeding events (RD 15.1 per 1000 person-years; HR 1.29) compared to lower doses (RD 6.7 per 1000 person-years; HR 1.13). The risk of major ischemic or hemorrhagic events was also elevated with higher diltiazem doses (HR 1.14).
In this cohort of Medicare patients with atrial fibrillation on apixaban or rivaroxaban, diltiazem usage was associated with a higher risk of severe bleeding events compared to metoprolol, especially at doses exceeding 120 mg per day. These findings underscore the importance of considering potential drug interactions and dose-related effects when prescribing diltiazem to patients on anticoagulant therapy, emphasizing the need for individualized treatment strategies to minimize the risk of adverse events in this population.
Link to the article: https://www.nature.com/articles/s41598-024-62962-8
References Ray, W. A., Chung, C. P., Stein, C. M., Smalley, W., Zimmerman, E., Dupont, W. D., Hung, A. M., Daugherty, J. R., Dickson, A., & Murray, K. T. (2024). Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban. JAMA, 331(18), 1565. https://doi.org/10.1001/jama.2024.3867
