This comparative effectiveness cohort study tests the hypothesis that use of direct
anticoagulants is associated with a lower risk of fracture compared with warfarin
therapy among patients with atrial fibrillation. Are oral anticoagulants differentially
associated with risk of fracture among patients with atrial fibrillation? In this
comparative effectiveness cohort study of 167 275 patients with atrial fibrillation,
direct oral anticoagulants (ie, dabigatran, rivaroxaban, and apixaban) were associated
with modestly lower fracture risk compared with warfarin. This protective association
was more pronounced among patients with atrial fibrillation who also had a diagnosis
of osteoporosis; among the direct oral anticoagulants, fracture risk was lowest among
apixaban users. These findings add to speculation that warfarin may be harmful to
bone health and suggest that direct oral anticoagulants may be preferred among patients
with atrial fibrillation and high fracture risk. Warfarin is prescribed to patients
with atrial fibrillation (AF) for the prevention of cardioembolic complications. Whether
warfarin adversely affects bone health is controversial. The availability of alternate
direct oral anticoagulant (DOAC) options now make it possible to evaluate the comparative
safety of warfarin in association with fracture risk. To test the hypothesis that,
among patients with nonvalvular AF, use of DOACs vs warfarin is associated with lower
risk of incident fracture. This comparative effectiveness cohort study used the MarketScan
administrative claims databases to identify patients with nonvalvular AF and who were
prescribed oral anticoagulants from January 1, 2010, through September 30, 2015. To
reduce confounding, patients were matched on age, sex, CHA 2 DS 2 -VASc (congestive
heart failure, hypertension, age [>65 years = 1 point; >75 years = 2 points], diabetes,
and previous stroke/transient ischemic attack [2 points], vascular disease) score,
and high-dimensional propensity scores. The final analysis included 167 275 patients
with AF. Data were analyzed from February 27, 2019 to September 18, 2019. Warfarin
and DOACs (dabigatran etexilate, rivaroxaban, and apixaban). Incident hip fracture,
fracture requiring hospitalization, and all clinical fractures (identified using inpatient
or outpatient claims) defined by International Classification of Diseases, Ninth
Revision, Clinical Modification codes. In the study population of 167 275 patients
with AF (38.0% women and 62.0% men; mean [SD] age, 68.9 [12.5] years), a total of
817 hip fractures, 2013 hospitalized fractures, and 7294 total fractures occurred
during a mean (SD) follow-up of 16.9 (13.7) months. In multivariable-adjusted, propensity
score–matched Cox proportional hazards regression models, relative to new users of
warfarin, new users of DOACs tended to be at lower risk of fractures requiring hospitalization
(hazard ratio [HR], 0.87; 95% CI, 0.79-0.96) and all clinical fractures (HR, 0.93;
95% CI, 0.88-0.98), whereas the association with hip fractures (HR, 0.91; 95% CI,
0.78-1.07) was not statistically significant. When comparing individual DOACs with
warfarin, the strongest findings were for apixaban (HR for hip fracture, 0.67 [95%
CI, 0.45-0.98]; HR for fractures requiring hospitalization, 0.60 [95% CI, 0.47-0.78];
and HR for all clinical fractures, 0.86 [95% CI, 0.75-0.98]). In subgroup analyses,
DOACs appeared more beneficial among patients with AF who also had a diagnosis of
osteoporosis than among those without a diagnosis of osteoporosis. In this real-world
population of 167 275 patients with AF, use of DOACs—particularly apixaban—compared
with warfarin use was associated with lower fracture risk. These associations were
more pronounced among patients with a diagnosis of osteoporosis. Given the potential
adverse effects of warfarin on bone health, these findings suggest that caution should
be used when prescribing warfarin to patients with AF at high risk of fracture.