Correct dosing, adherence and persistence of DOACs in atrial fibrillation and chronic kidney disease: a systematic review and meta-analysis

Emanuel, Subo; Kaba, Riyaz A.; Delanerolle, Gayathri; Field, Benjamin; Lip, Gregory Y.H.; Lusignan, Simon de

doi:10.1136/openhrt-2023-002340

Cited by 2 publications

(1 citation statement)

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“…Lack of high-quality evidence in CKD has led to differences in recommendations by various professional bodies adding on to this confusion [ 7 ]. This has thus led to underutilization of DOACs in CKD patients [ 8 ]. In this article, we focus on the pharmacokinetics and current clinical evidence on the use of DOACs in patients with CKD.…”

Section: Introductionmentioning

confidence: 99%

Anticoagulation in Patients with Chronic Kidney Disease

Elenjickal,

Travlos,

Marques

et al. 2023

Am J Nephrol

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Background: Both atrial fibrillation and venous thromboembolic disease (VTE) are highly prevalent among patients with chronic kidney disease (CKD). Until recently, warfarin was the most commonly prescribed oral anticoagulant. Direct oral anticoagulants (DOACs) have important advantages and have been shown to be non-inferior to warfarin with respect to stroke prevention or recurrent VTE in the general population, with lower bleeding rates. This review article will provide available evidence on use of DOACs in patients with CKD. Summary: In post-hoc analyses of major randomized studies with DOACs for stroke prevention in atrial fibrillation, in the subgroup of participants with moderate CKD, defined as a creatinine clearance (CrCl) of 30-50 ml/min, dabigatran 150 mg and apixaban were associated with lower rates of stroke and systemic embolism, whereas apixaban and edoxaban were associated with lower bleeding and mortality rates, compared with warfarin. In retrospective observational studies in patients with advanced CKD (defined as a CrCl <30 ml/min) and atrial fibrillation, DOACs had similar efficacy with warfarin with numerically lower bleeding rates. All agents warrant dose adjustment in moderate to severe CKD. In patients on maintenance dialysis, the VALKYRIE trial which was designed initially to study the effect of vitamin K on vascular calcification progression, established superiority for rivaroxaban compared with a vitamin K antagonist (VKA) in the extension phase. Two other clinical trials using apixaban (AXADIA and RENAL-AF) in this population were inconclusive due to recruitment challenges and low event rates. In post-hoc analyses of randomized studies with DOACs in patients with VTE, in the subgroup of participants with moderate CKD at baseline, edoxaban was associated with lower rates of recurrent VTE, whereas rivaroxaban and dabigatran were associated with lower and higher bleeding rates, respectively, as compared to warfarin. Key messages: DOACs have revolutionized the management of atrial fibrillation and VTE and they should be preferred over warfarin in patients with moderate-to-severe CKD with appropriate dose adjustment Therapeutic drug monitoring with a valid technique may be considered to guide clinical management in individualized cases. Current evidence questions the need for oral anticoagulation in patients on maintenance dialysis with atrial fibrillation, as both DOACs and VKAs are associated with high rates of major bleeding.

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Section: Introductionmentioning

confidence: 99%