Safety and Efficacy of Direct Oral Anticoagulants for Atrial Fibrillation in Patients with Renal Impairment

Abstract

Direct oral anticoagulants (DOACs) are gaining popularity for patients with nonvalvular atrial fibrillation (AF) for stroke prevention. Less bleeding risk with comparable stroke prevention compared to warfarin was shown. DOACs have predictable anticoagulant effects, infrequent monitoring requirements and less drug-food interactions compared to warfarin. However, safety and efficacy data of DOACs in patients with chronic kidney disease (CKD) are limited. This is a retrospective study to evaluate thromboembolic and bleeding events in patients with AF (with/without CKD) in October 2010 and July 2017. A total of 495 patients were included and only 150 patients had CKD. Our study found that patients with renal impairment on a DOAC do not have a higher incidence of bleeding events. It showed significant increase in thromboembolic events in CKD patients with dabigatran compared to CKD patients with apixaban with odds ratio of 6.58 (95%CI 1.35-32.02, p = 0.02).

Specifics of anticoagulation in combination with atrial fibrillation and chronic kidney disease

“…В итоге достоверная разница в частоте "больших" кровотечений между группами отсутствовала (14% vs 7%, соответственно, p=0,362). В исследовании Jang SM, et al (n=495) у пациентов с ТПН с ФП данный ПОАК также не увеличивал риск кровотечений при сравнении безопасности и эффективности с варфарином [34], а дабигатран достоверно увеличил частоту тромбоэмболических осложнений, по сравнению с группой апиксабана. В крупном систематическом обзоре по применению антикоагулянтной терапии при ФП и ХБП Feldberg J, et У больных с ХБП IV-V (ТБП) метаанализы с большим количеством пациентов продемонстрировали, что варфарин и апиксабан предотвращали тромбоэмболии примерно одинаково, а последний был связан со значительно более низким риском кровотечения [27,32].…”

“…Сокращения: ДИ -доверительный интервал, ОР -отношение рисков.ПОАК и варфарином, однако у диализных пациентов приём ривароксабана и дабигатрана в отличие от апиксабана увеличил частоту кровотечений[29]. Схожие данные были получены и в исследованиях Jang SM, et al[34] и Stanifer JW, et al[35] (рис. 4).…”

Direct oral anticoagulant use in special populations

“…In a retrospective review of patients with NVAF on dialysis anticoagulated with apixaban (n ¼ 2351) or warfarin (prognostic score matched 1 : 3), there was no difference in rate of thromboembolic events but significantly lower risk of major bleeding in those treated with apixaban, with apixaban 5 mg twice daily associated with significantly lower rates of stroke/systemic embolism and mortality compared with either reduced-dose apixaban or warfarin [44]. Evidence supporting the use of other DOACs in advanced CKD or ESKD is less robust, with conflicting evidence on the safety profiles of rivaroxaban [45][46][47] and evidence of potential harm with dabigatran [47,48].…”

Healthcare Professionals and Undergraduate Students’ Knowledge Toward Drug-Food Interactions in the Eastern Region of Saudi Arabia

“…For instance, a vitamin K-enriched diet antagonizes the anticoagulant therapeutic effects of warfarin. 12 The prevalence of DFI varies greatly between countries, ranging from 6% to 70%. 5 Due to the magnitude of the effect of food on oral drug bioavailability, the United States Food and Drug Administration (FDA), followed by the European Medicines Agency (EMA), issued a regulation for preforming bioavailability as well as bioequivalence experiments under fed conditions.…”