NOACs linked to lower rates of diabetes complications than warfarin in patients with afib and diabetes
A retrospective study from Taiwan found that patients who received non-vitamin K antagonist oral anticoagulants (NOACs) developed fewer macrovascular and microvascular complications, had fewer glycemic emergencies, and were less likely to die than those who received warfarin.
Use of non-vitamin K antagonist oral anticoagulants (NOACs) was associated with lower rates of diabetes-related complications and mortality than use of warfarin in patients with atrial fibrillation and diabetes, a retrospective study found.
Researchers used a national database to assess patients with atrial fibrillation and diabetes who received NOACs or warfarin between 2012 and 2017 in Taiwan. They excluded patients with rheumatic heart disease, congenital heart disease, valve replacement surgery, or end-stage renal disease at baseline because they were more likely to receive warfarin than NOACs. The four primary outcomes included macrovascular complications (composite outcome of coronary artery disease, stroke, and peripheral vascular disease), microvascular complications (composite outcome of retinopathy, neuropathy, dialysis, and lower-extremity amputations), glycemic emergency (composite outcome of diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia), and all-cause mortality. Results were published Feb. 15 by Annals of Internal Medicine.
A total of 19,909 NOAC users (mean age, 73.8 years; 54.3% male) and 10,300 warfarin users (mean age, 73.9 years; 54.3% male) were included in the analysis, and the overall mean follow-up duration was 2.9 years. Patients who received NOACs had significantly lower risk of macrovascular complications (hazard ratio [HR], 0.84 [95% CI, 0.78 to 0.91]; P<0.001), microvascular complications (HR, 0.79 [95% CI, 0.73 to 0.85]; P<0.001), glycemic emergencies (HR, 0.91 [95% CI, 0.83 to 0.99]; P=0.043), and mortality (HR, 0.78 [95% CI, 0.75 to 0.82]; P<0.001) than those receiving warfarin. Analyses with propensity score matching showed similar results, and several sensitivity analyses supported the robustness of the findings. Of note, 46% of warfarin users changed their oral anticoagulation to a NOAC during follow-up.
Among other limitations, the researchers pointed out that they could not obtain certain patient data, such as substance use, body mass index, or international normalized ratios. They added that they verified diagnostic accuracy by using diagnostic and procedure codes rather than by directly accessing patients' medical records.
Several factors may explain the findings, including the difference in anticoagulation mechanism between NOACs and warfarin or the potential for the latter's antagonization of vitamin K to lead to impaired insulin sensitivity and glucose tolerance, the authors noted. They concluded that “NOAC may be a better therapeutic choice than warfarin for decreasing these complications and mortality in patients with [atrial fibrillation] and [diabetes] requiring oral anticoagulant treatment.”