A Review of Direct Oral Anticoagulants in Patients With Stage 5 or End-Stage Kidney Disease

Starr, Jessica; Pinner, Nathan A.; Mannis, Melanie; Stuart, Mary

doi:10.1177/10600280211040093

Cited by 8 publications

(9 citation statements)

References 45 publications

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“…3,23 Despite these recommendations, limited clinical data exist supporting DOACs in the treatment of VTE in patients with CKD stage 5 (ie, glomerular filtration rate <15 mL/min/1.73 m 2 ) or dependent on dialysis. 24 While the majority of pharmacists surveyed preferred a DOAC in the setting of renal impairment, more than one-third of pharmacists preferred warfarin in patients with CKD stage 5. These data highlight that, despite FDA-approved labeling, a notable proportion of pharmacists are uncomfortable with DOAC utilization in patients with CKD stage 5 or dependent on dialysis.…”

Section: Discussionmentioning

confidence: 99%

Pharmacist Practice Patterns Regarding Direct Oral Anticoagulants for Treatment of Venous Thromboembolism

et al. 2022

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Background: Direct oral anticoagulants (DOACs) are increasingly prescribed for the treatment of venous thromboembolism (VTE). However, little is known regarding pharmacists’ practice patterns and preferences in clinical areas of contention, such as initiation dosing, obesity, and renal impairment. Objective: To determine pharmacist trends in practice regarding DOACs for the treatment of VTE overall and within areas of clinical controversy. Methods: An electronic survey was distributed to pharmacists in the United States through national and state pharmacy organizations. Responses were collected for 30 days. Results: One hundred fifty-three complete responses were submitted. The majority of pharmacists preferred apixaban (90.2%) for the oral treatment of venous thromboembolism. When initiating apixaban or rivaroxaban for a new VTE, 76% and 64% of pharmacists surveyed, respectively, state the duration of the initiation dose phases are reduced if the patient received parenteral anticoagulation. Fifty-eight percent of pharmacists used body mass index to evaluate the appropriateness of DOACs in obese patients whereas 42% used total body weight. Preference for rivaroxaban (31.4%) was higher in this population compared to the global population (10%). Apixaban was preferred for patients with renal impairment (92.2%). However, as creatinine clearance as calculated by the Cockcroft-Gault equation (CrCl) reduced to ≤15 milliliters/minute (mL/min), preference for warfarin increased (36%). Conclusion: This national survey of pharmacists demonstrated an overall preference for apixaban and significant variability in practice patterns regarding DOACs for patients with new VTE, patients with obesity, and patients with renal impairment. Further research is warranted to evaluate the efficacy and safety of DOAC initiation dosing phase modifications. Prospective evaluations of DOACs in obese and renal dysfunction populations would confirm the safety and efficacy of DOACs in these populations.

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Section: Discussionmentioning

confidence: 99%

Pharmacist Practice Patterns Regarding Direct Oral Anticoagulants for Treatment of Venous Thromboembolism

et al. 2022

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“…Furthermore, one smartwatch has the additional functionality of performing a single lead electrocardiogram (ECG), which improved the accuracy over its PPG-based algorithm [ 18 ]. However, it remains to be determined whether the additional detection of AF is clinically relevant in patients with ESKD, as consensus on the appropriateness and method of anticoagulant treatment remains unclear in this population [ 20 ]. For the detection of bradyarrhythmias using smartwatch-derived signals, only anecdotal reports are available and, again, not in the CKD or ESKD populations [ 21 ].…”

Section: Wearable Devices For Diagnosis and Monitoring In Ckdmentioning

confidence: 99%

Wearables in Nephrology: Fanciful Gadgetry or Prêt-à-Porter?

Stauss

Htay

Kooman

et al. 2023

Sensors

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Telemedicine and digitalised healthcare have recently seen exponential growth, led, in part, by increasing efforts to improve patient flexibility and autonomy, as well as drivers from financial austerity and concerns over climate change. Nephrology is no exception, and daily innovations are underway to provide digitalised alternatives to current models of healthcare provision. Wearable technology already exists commercially, and advances in nanotechnology and miniaturisation mean interest is also garnering clinically. Here, we outline the current existing wearable technology pertaining to the diagnosis and monitoring of patients with a spectrum of kidney disease, give an overview of wearable dialysis technology, and explore wearables that do not yet exist but would be of great interest. Finally, we discuss challenges and potential pitfalls with utilising wearable technology and the factors associated with successful implementation.

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“…[4][5][6][7][8][9][10][11] This is unfortunate, as all commercially available DOACs are partially or primarily eliminated renally, and dosing recommendations are predominantly based on single-dose pharmacokinetic studies. 12 Thus, there are minimal data describing the efficacy and safety of these agents in patients with moderate to severe and end-stage chronic kidney disease (CKD), and studies are limited to subgroup analyses of landmark clinical trials and retrospective studies. [12][13][14][15][16][17] The 2019 AHA/ACC/HRS atrial fibrillation guidelines focused update recommends DOACs over warfarin in patients with normal renal function and either warfarin or apixaban in patients with end-stage renal disease (ESRD) and CrCl < 15 mL/min or on dialysis, though there are no well-designed clinical trials to support this recommendation.…”

Section: Introductionmentioning

confidence: 99%

“…12 Thus, there are minimal data describing the efficacy and safety of these agents in patients with moderate to severe and end-stage chronic kidney disease (CKD), and studies are limited to subgroup analyses of landmark clinical trials and retrospective studies. [12][13][14][15][16][17] The 2019 AHA/ACC/HRS atrial fibrillation guidelines focused update recommends DOACs over warfarin in patients with normal renal function and either warfarin or apixaban in patients with end-stage renal disease (ESRD) and CrCl < 15 mL/min or on dialysis, though there are no well-designed clinical trials to support this recommendation. 1 Furthermore, there are limited studies comparing the safety and efficacy of DOACs and warfarin in patients hospitalized with acute kidney injury (AKI); therefore, the safety of DOACs in this patient population remains unknown.…”

Section: Introductionmentioning

confidence: 99%

The Safety of Direct Oral Anticoagulants Compared to Warfarin in Patients Hospitalized With Acute Kidney Injury

2022

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Background: Direct oral anticoagulants (DOACs) are preferred over warfarin for many indications, though their safety has not been well established in patients with acute renal impairment. Objective: The purpose of this study was to evaluate the frequency of bleeding complications associated with DOACs compared with warfarin in patients admitted to the hospital with acute kidney injury (AKI). Methods: This was a retrospective cohort study evaluating patients admitted to the Penn Medicine Lancaster General Hospital with a diagnosis of AKI from October 2017 through September 2021 and receiving therapy with oral anticoagulants. Comparing DOACs with warfarin, the primary endpoint was the percent frequency of composite major and minor bleeding during the admission and within 30 days of discharge. Results: There were 112 hospitalization encounters included in the study. Of these, 42 (37.5%) patients were receiving warfarin and 70 (62.5%) patients were receiving DOAC therapy before admission. There was a higher frequency of the primary endpoint of bleeding in patients receiving DOACs as compared with warfarin, though this was not statistically significant (18.5% vs. 11.9%, respectively, P = 0.432). There were no differences between groups in the frequency of major bleeding, minor bleeding, or transfusions. Patients receiving DOAC therapy were more likely to experience anticoagulation-related readmissions or emergency department visits compared with patients on warfarin therapy (11.4% vs. 0%, P = 0.024). Conclusion and Relevance: Direct oral anticoagulants and warfarin were associated with statistically similar rates of bleeding in patients presenting with AKI. Further research is necessary to elucidate if DOACs are safer than warfarin in this patient population.

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A Review of Direct Oral Anticoagulants in Patients With Stage 5 or End-Stage Kidney Disease

Cited by 8 publications

References 45 publications

Pharmacist Practice Patterns Regarding Direct Oral Anticoagulants for Treatment of Venous Thromboembolism

Pharmacist Practice Patterns Regarding Direct Oral Anticoagulants for Treatment of Venous Thromboembolism

Wearables in Nephrology: Fanciful Gadgetry or Prêt-à-Porter?

The Safety of Direct Oral Anticoagulants Compared to Warfarin in Patients Hospitalized With Acute Kidney Injury

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