Anticoagulant strategies for the patient with chronic kidney disease

Law, Jonathan P; Pickup, Luke; Townend, Jonathan; Ferro, Charles J.

doi:10.7861/clinmed.2019-0445

Cited by 12 publications

(10 citation statements)

References 23 publications

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“…When clinical practice guidelines recommend warfarin therapy in patients with CKD, it is suggested that drug dose adjustment is not necessary because warfarin is eliminated by hepatic metabolism [17,20]. However, considering warfarin's narrow therapeutic window and its susceptibility to multiple drug and food interactions, interpretation of dose adjustment solely on the basis of estimated glomerular ltration rate (eGFR) may be an over-simpli ed approach under uremia and downregulation of CYP450 in these patients [11,21]. In fact, several clinical studies have shown that patients with CKD require lower warfarin dosages to maintain therapeutic anticoagulation compared to patients with normal kidney function [22,23].…”

Section: Discussionmentioning

confidence: 99%

“…Despite these advantages of NOACs over VKAs, NOAC therapy requires caution in patients with CKD. Although varying in degrees, all NOACs are dependent on the kidney for elimination, so their use makes dose adjustment mandatory in patients with CKD [11,32]. Unfortunately, there is no standardized test for monitoring NOACs to con rm maintenance of therapeutic anticoagulation in these patients after dose adjustment.…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, clinical guidelines recommend oral anticoagulant therapy in patients with AF [3,10]. However, patients with CKD are not only at a higher risk of ischemic stroke but also at an increased risk of bleeding even without oral anticoagulants [11]. Although vitamin K antagonists (VKAs), such as warfarin, are highly effective in the prevention of ischemic stroke, the narrow therapeutic window requiring frequent monitoring and dose adjustments may result in potentially subtherapeutic or toxic effects, particularly in patients with CKD.…”

Section: Introductionmentioning

confidence: 99%

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Non-Vitamin K Antagonist Anticoagulants versus Warfarin in newly diagnosed Atrial Fibrillation and CKD: the Korean National Health Insurance Data

Kee

Jeon

et al. 2022

Preprint

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Background: Despite the benefits of non-vitamin K antagonist oral anticoagulants (NOACs), whether NOAC therapy has a better risk-benefit profile than warfarin therapy in patients with non-valvular atrial fibrillation (AF) and chronic kidney disease (CKD), including end-stage renal disease (ESRD), remains uncertain. We investigated the efficacy and safety of NOACs compared to warfarin in these patients using a nationwide database.Methods: We evaluated patients with incident non-valvular AF and CKD in the Korea National Health Insurance Database from 2013 to 2018. The primary and secondary efficacy outcomes were ischemic stroke and all-cause mortality, respectively. The primary safety outcomes included intracranial hemorrhage, gastrointestinal bleeding, and extracranial or unclassified major bleeding.Results: Among the 1,885 patients, 970 (51.5%) initiated warfarin therapy, whereas 915 (48.5%) initiated NOAC therapy. Although NOAC users had a lower proportion of patients with ESRD than warfarin users (6.6% vs. 32.5%, p <0.001), NOAC users had a higher Charlson comorbidity index, CHA2DS2-VASC score, and modified HAS-BLED score compared with warfarin users. During a mean follow-up period of 23.8 months, there were 293 and 214 cases of ischemic stroke and all-cause death, respectively. There was no difference in ischemic stroke between the two groups. However, Kaplan-Meier survival analysis showed that all-cause mortality was significantly lower in NOAC users than in warfarin users. In multivariate Cox regression analyses, the hazard ratio for all-cause mortality compared to warfarin therapy was 0.41 (95% CI, 0.30-0.56; p < 0.001) in NOAC therapy. Additionally, NOAC therapy significantly reduced intracranial hemorrhage and gastrointestinal bleeding in multivariate Cox regression analyses.Conclusions: This study showed that NOAC therapy had a better risk-benefit profile than warfarin therapy in patients with AF and CKD. To clarify the benefits of NOACs in patients with AF and CKD, further well-designed clinical trials are needed.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Non-Vitamin K Antagonist Anticoagulants versus Warfarin in newly diagnosed Atrial Fibrillation and CKD: the Korean National Health Insurance Data

Kee

Jeon

et al. 2022

Preprint

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“…For example, renal failure is common in acute COVID-19. Thus, heparins, especially unfractionated heparin, are a safer anticoagulation choice due to DOACs' renaldependent metabolism (40). Furthermore, heparin binds to COVID-19 spike proteins and IL-6, which are elevated in COVID-19 patients (41).…”

Section: Are Doacs An Option For Anticoagulation In Covid-19 Hospital...mentioning

confidence: 99%

The role of direct oral anticoagulants in the era of COVID-19: are antiviral therapy and pharmacogenetics limiting factors?

et al. 2022

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In patients with COVID-19, thromboinflammation is one of the main causes of morbidity and mortality, which makes anticoagulation an integral part of treatment. However, pharmacodynamic and pharmacokinetic properties of direct oral anticoagulants (DOACs) limit the use of this class of anticoagulants in COVID-19 patients due to a significant interference with antiviral agents. DOACs use in COVID-19 hospitalized patients is currently not recommended. Furthermore, patients already on oral anticoagulant drugs should be switched to heparin at hospital admission. Nevertheless, outpatients with a confirmed diagnosis of COV-ID-19 are recommended to continue prior DOAC therapy. More studies are required to clarify the pathogenesis of COVID-19-induced derangement of the coagulation system in order to recommend an appropriate anticoagulant treatment.

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“…Compared to the general population, advanced CKD patients are at an increased risk of Atrial Fibrillation (AF) and Venous Thromboembolism (VTE), warranting short and long-term anticoagulation treatment [4][5][6]. Advanced CKD patients are also at an increased risk of bleeding, making it difficult to choose an optimal anticoagulant agent for this population [5].…”

Section: Introductionmentioning

confidence: 99%

Safety and Efficacy of Apixaban vs Warfarin in Patients With Stage 4 and 5 Chronic Kidney Disease: A Systematic Review

Fatima¹,

Nwankwo²,

Anam³

et al. 2022

Cureus

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Warfarin has been an anticoagulant of choice in patients with advanced Chronic Kidney Diseases (CKD) at stages 4 and 5 for decades, but with the advent of Novel Oral Anticoagulants (NOACs), there has been a sharp rise in their prescriptions. Among all NOACS, apixaban is the least reliant on kidney function and is a very popular choice for this patient population. However, being utilized extensively, most of the landmark trials evaluating the safety and efficacy of apixaban excluded patients with Creatinine Clearance (CrCl) <25mL/min/1.73 m 2 or Serum Creatinine (SCr) ≥2.5mg/dL. Its approval for advanced CKD patients came from limited pharmacokinetic data only. We conducted a systematic review comparing the safety and efficacy of apixaban to warfarin in patients with stage 4 and 5 CKD and on dialysis.We queried major research literature databases, including MEDLINE, PubMed, PubMed Central (PMC), Cochrane Central, and ScienceDirect to find relevant articles without any time or language restrictions. After screening and quality checks, we identified 11 studies relevant to our research question, of which nine were retrospective cohort studies, one was a post-hoc analysis of a randomized controlled trial (RCT), and one was an RCT. The included studies had a total of 27,007 patients, with 4,335 patients taking apixaban and 22,672 on warfarin. The results indicate that the overall efficacy of apixaban was equivalent to warfarin for the prevention of stroke, systemic embolization, and recurrent venous thromboembolism, but apixaban showed an equivalent and, in some studies, better safety profile than warfarin concerning the occurrence of bleeding. Apixaban may hence be considered a reasonable alternative to warfarin in patients with Stage 4 or 5 CKD and receiving dialysis. In light of the reviewed articles, we conclude that apixaban has similar efficacy and somewhat superior safety profile to warfarin, with more randomized controlled trials required to add to the evidence.

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Anticoagulant strategies for the patient with chronic kidney disease

Cited by 12 publications

References 23 publications

Non-Vitamin K Antagonist Anticoagulants versus Warfarin in newly diagnosed Atrial Fibrillation and CKD: the Korean National Health Insurance Data

Non-Vitamin K Antagonist Anticoagulants versus Warfarin in newly diagnosed Atrial Fibrillation and CKD: the Korean National Health Insurance Data

The role of direct oral anticoagulants in the era of COVID-19: are antiviral therapy and pharmacogenetics limiting factors?

Safety and Efficacy of Apixaban vs Warfarin in Patients With Stage 4 and 5 Chronic Kidney Disease: A Systematic Review

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