Potential Risk of Serious Bleeding in Patients With AF Using Diltiazem With Apixaban or Rivaroxaban

A potentially serious drug interaction between diltiazem and apixaban or rivaroxaban has been reported in US Medicare patients taking these drugs together for atrial fibrillation. The study has been published as online ahead of print in the Journal of American Medical Asociation [1]. The study compared serious bleeding risk for new users of apixaban or rivaroxaban with atrial fibrillation treated with diltiazem or metoprolol. It was a retrospective cohort study which included US Medicare benefiaries aged 65 years or more with atrial fibrillation and follow up period was one year. Primary outcome was a composite of bleeding-related hospitalization and death with recent evidence of bleeding. Ischemic stroke, systemic embolism, intracranial or fatal extracranial bleeding and death with recent evidence of bleeding were the secondary outcomes evaluated.

The study had over two hundred thousand US Medicare beneficiaries of which about fifty three thousand received diltiazem while about one hundred and fifty thousand received metoprolol. Mean age was 76.9 years and there was over ninety thousand person-years of follow up. Patients receiving diltiazem had increased risk of primary outcome and its components of bleeding-related hospitalization and death with recent evidence of bleeding. Risk was higher in those receiving initial dose of diltiazem exceeding 120mg/d.

Reference

1. Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban. JAMA. 2024 Apr 15:e243867. doi: 10.1001/jama.2024.3867. Epub ahead of print. PMID: 38619832; PMCID: PMC11019444.