Comparison of outcomes in non-head injured trauma patients using pre-injury warfarin or direct oral anticoagulant therapy. Issue 11 (November 2020) - van Erp, Inge A
Highlights: Warfarin users receive more anticoagulation reversal than DOAC users. DOAC use is not associated with higher mortality despite higher average ISS. DOAC use is not associated with more transfusion despite higher average ISS. Abstract: Background: Patients on prehospital anticoagulation with warfarin or direct oral anticoagulants (DOACs) represent a vulnerable subset of the trauma population. While protocolized warfarin reversal is widely available and easily implemented, prehospital anticoagulation with DOAC is cost prohibitive with only a few reversal options. This study aims to compare hospital outcomes of non-head injured trauma patients taking pre-injury DOAC versus warfarin. Methods: A retrospective cohort study at a level 1 trauma center was performed. All adult trauma patients with pre-injury anticoagulation admitted between January 2015 and December 2018, were stratified into DOAC-using and warfarin-using groups. Patients were excluded if they had traumatic brain injury (TBI). Univariate and multivariable analyses were performed. Outcomes measures included in-hospital mortality, blood transfusion requirements, ICU length of stay (LOS), hospital LOS and discharge disposition. Results: 374 non-TBI trauma patients on anticoagulation were identified, of which 134 were on DOACs and 240 on warfarin. Patients on DOACs had a higher ISS (9 [IQR, 9–10] vs. 9 [IQR, 5–9]; p <0.001), and lower admission INR values (1.2 [IQR, 1.1–1.3] vs 2.4 [IQR, 1.8–2.7]; p <0.001) than warfarin users. Use of reversal agents was higher in warfarin users ( p <0.001). Relative to warfarin, DOAC users did not differ significantly with respect to hospital mortality (OR 0.47, 95% CI [0.13–1.73]). Multivariable analysis (not possible for mortality) did not show significant difference for RBC transfusion requirements (OR 0.92 [0.51–1.67]), ICU LOS (OR 1.08 [0.53–2.19]), hospital LOS (OR 1.10 [0.70–1.74]) or discharge disposition (OR 0.56 [0.29–1.11]) between the groups. Conclusion: Despite lower reversal rates and higher ISS, non-TBI trauma patients with pre-injury DOAC use had similar outcomes as patients on pre-injury warfarin. There may be equipoise to have larger, prospective studies evaluating the comparative safety of DOACs and warfarin in the population prone to low energy fall type injuries.