Background: Studies investigating the association between the use of oral
anticoagulants (OACs) and
osteoporosis are limited. We aimed to determine the risk of
osteoporosis in patients with
atrial fibrillation (AF) and receiving different OACs. Methods: We performed a population-based cohort study using a nationwide primary care dataset, MedicineInsight. Patients aged between 18 and 111 years with AF and newly recorded OAC prescriptions between 1 January 2013 and 31 December 2017 were included and followed until 31 December 2018. We applied propensity score matching to control for patients’ baseline characteristic differences before calculating adjusted hazard ratios (aHRs) for a new diagnosis of
osteoporosis, using Cox proportional hazard models. Results: A total of 18,454 patients (1714 prescribed
dabigatran, 5871
rivaroxaban, 5248
apixaban and 5621
warfarin) were included. Of these, 39.5% were females, and the overall mean age (standard deviation [SD] was 73.2(10.3) years. Over a mean follow-up of 841 days, 1627 patients (1028 receiving
direct-acting oral anticoagulants (DOACs) and 599
warfarin) had a newly recorded diagnosis of
osteoporosis. The weighted incidence rates (95% confidence interval; CI) per 100 person-years of treatment were 5.0 (4.7−5.2) for
warfarin, 4.3 (3.8−4.8) for
dabigatran, 3.6 (3.3−3.8) for
rivaroxaban, and 4.4 (4.0−4.7) for
apixaban. Overall, DOAC use was associated with a significantly lower risk of a new diagnosis of
osteoporosis than
warfarin use (aHR, 0.79, 95% confidence interval (CI) 0.74−0.85; p < 0.001). Use of each individual DOAC was associated with a significantly lower risk of
osteoporosis compared with
warfarin (aHRs, 0.75, 95% CI 0.69−0.82 for
rivaroxaban; 0.78, 95% CI 0.71−0.86 for
apixaban; 0.88, 95% CI 0.77−0.99 for
dabigatran). Conclusion: Compared with
warfarin, the use of DOACs was associated with a significantly lower risk of developing
osteoporosis in patients with AF. This association remained significant when individual DOACs were compared with
warfarin.