Risk of intracranial hemorrhage between different direct oral anticoagulants in older patients seen in the emergency department with a head injury: A population-based cohort study

INTRODUCTION: Patients taking direct oral anticoagulants (DOACs) are increasingly managed in emergency departments (ED). It is unknown whether the risk of traumatic intracranial hemorrhage (ICH) after a head injury differs between DOACs. The objective of this study was to compare risk of ICH at the index ED visit among older adults presenting to the ED with a head injury prescribed different DOACs. METHODS: Retrospective cohort study using population-based administrative databases from Ontario, Canada between 2016 and 2018 of patients age 65 years and older prescribed DOACs who were seen in the ED with a head injury. Patients were matched on the propensity score to create three pairwise-matched cohorts based on the DOAC prescribed (dabigatran vs rivaroxaban; dabigatran vs apixaban; rivaroxaban vs apixaban). For each cohort, relative risk (RR) and 95% confidence intervals (CI) of ICH diagnosed at the index ED visit were calculated. RESULTS: We identified 9230 older adults presenting with a head injury prescribed a DOAC. There were 1274 (13.8%) patients with a prescription for dabigatran, 3136 (34.0%) patients with a prescription for rivaroxaban, and 4820 (52.2%) patients with a prescription for apixaban. Overall, 5.9% of patients had an ICH at the index ED visit. After matching, there were no significant differences in the risk of ICH between any matched DOAC cohorts. CONCLUSION: In patients aged 65 years and older with a prescription for a DOAC seen in the ED for a head injury, there were no differences in the risk of ICH between DOACs.