【文献Abstract】抗血栓薬投与と血尿関連合併症

〈要点〉

・カナダの66歳以上、抗凝固薬、抗血小板薬服薬中の患者約80万人に対し約7年の後ろむきコホートを実施
・患者の基礎疾患は狭心症15％、心筋梗塞3.9％、TIA3.9%、末梢血管疾患3,4%、心房細動3.3％。抗血栓薬は、80万人中アスピリン31500例、他の抗血小板薬27500例、アピキサバン15000例、ダビガトラン43500例、リバーロキサバン88000例、ワルファリン32万例使用されていた。
・そのうち血尿関連合併症は、1000人年あたり、アスピリン94.3、他の抗血小板薬130.03、アピキサバン164.09、ダビガトラン144.24、リバーロキサバン188.65、ワルファリン138.67。また、抗血栓薬服用者は非服用者に比べ、膀胱癌と診断される確率が1.85倍、前立腺肥大のある人はない人よりも血尿合併症が多いという結果も。
・結論：高齢者においては、抗血栓薬による血尿関連合併症が多い。

〈雑感〉

・簡単に要約すると、抗血栓薬投与で年間10人に1人強、抗凝固薬抗と血小板薬併用だと5人に1人が何らかの処置の必要な血尿があったとのこと。
・血尿をとめるために内服を中止するのか、それとも合併症を予防するために内服を継続するか、ときどき悩むことがありますが、こんなに多いとは意外でした・・・

〈文献〉

Association Between Use of Antithrombotic Medication and Hematuria-Related Complications
Christopher J. D. Wallis, MD, PhD; Tristan Juvet, MD; Yuna Lee, MD, MEd; et alRano Matta, MD, MSc; Sender Herschorn, MD; Ronald Kodama, MD; Girish S. Kulkarni, MD, PhD; Raj Satkunasivam, MD, MPH; William Geerts, MD5; Anne McLeod, MD; Steven A. Narod, MD; Robert K. Nam, MD, MSc
JAMA. 2017;318(13):1260-1271. doi:10.1001/jama.2017.13890

Key Points
Question Is there an association between the use of oral antithrombotic agents and hematuria-related complications?

Findings In this cohort study that included 2 518 064 older adults in Ontario, Canada, use of antithrombotic medications, compared with nonuse of these medications, was significantly associated with hematuria-related complications (including emergency department visits, hospitalizations, and urologic procedures).

Meaning Use of antithrombotic medications was associated with a significant increase in rates of hematuria-related complications.

Abstract
Importance Antithrombotic medications are among the most commonly prescribed medications.

Objective To characterize rates of hematuria-related complications among patients taking antithrombotic medications.

Design, Setting, and Participants Population-based, retrospective cohort study including all citizens in Ontario, Canada, aged 66 years and older between 2002 and 2014. The final follow-up date was December 31, 2014.

Exposures Receipt of an oral anticoagulant or antiplatelet medication.

Main Outcomes and Measures Hematuria-related complications, defined as emergency department visit, hospitalization, or a urologic procedure to investigate or manage gross hematuria.

Results Among 2 518 064 patients, 808 897 (mean [SD] age, 72.1 [6.8] years; 428 531 [53%] women) received at least 1 prescription for an antithrombotic agent over the study period. Over a median follow-up of 7.3 years, the rates of hematuria-related complications were 123.95 events per 1000 person-years among patients actively exposed to antithrombotic agents vs 80.17 events per 1000 person-years among patients not exposed to these drugs (difference, 43.8; 95% CI, 43.0-44.6; P < .001, and incidence rate ratio [IRR], 1.44; 95% CI, 1.42-1.46). The rates of complications among exposed vs unexposed patients (80.17 events/1000 person-years) were 105.78 for urologic procedures (difference, 33.5; 95% CI, 32.8-34.3; P < .001, and IRR, 1.37; 95% CI, 1.36-1.39), 11.12 for hospitalizations (difference, 5.7; 95% CI, 5.5-5.9; P < .001, and IRR, 2.03; 95% CI, 2.00-2.06), and 7.05 for emergency department visits (difference, 4.5; 95% CI, 4.3-4.7; P < .001, and IRR, 2.80; 95% CI, 2.74-2.86). Compared with patients who were unexposed to thrombotic agents, the rates of hematuria-related complications were 191.61 events per 1000 person-years (difference, 117.3; 95% CI, 112.8-121.8) for those exposed to both an anticoagulant and antiplatelet agent (IRR, 10.48; 95% CI, 8.16-13.45), 140.92 (difference, 57.7; 95% CI, 56.9-58.4) for those exposed to anticoagulants (IRR, 1.55; 95% CI, 1.52-1.59), and 110.72 (difference, 26.5; 95% CI, 25.9-27.0) for those exposed to antiplatelet agents (IRR, 1.31; 95% CI, 1.29-1.33). Patients exposed to antithrombotic agents, compared with patients not exposed to these drugs, were more likely to be diagnosed as having bladder cancer within 6 months (0.70% vs 0.38%; odds ratio, 1.85; 95% CI, 1.79-1.92).

Conclusions and Relevance Among older adults in Ontario, Canada, use of antithrombotic medications, compared with nonuse of these medications, was significantly associated with higher rates of hematuria-related complications (including emergency department visits, hospitalizations, and urologic procedures to manage gross hematuria).