What is the current evidence for the pharmacology, utilization, and safety of direct oral anticoagulants in patients with end-stage renal disease and atrial fibrillation?
This review highlights the controversial and evolving use of DOACs for stroke prevention in patients with ESRD and atrial fibrillation, emphasizing the need for careful consideration of their pharmacology and safety.
Patients with end-stage renal disease (ESRD) were excluded from pivotal clinical trials with oral anticoagulants. While such patients are at an increased risk of venous and arterial thromboembolism, their risk of bleeding is also elevated. It is thus of little surprise that stroke prevention with vitamin K antagonists (VKAs) in ESRD patients with atrial fibrillation is controversial, with observational evidence ranging from beneficial to harmful. This uncertainty extends to the less studied use of VKAs for venous thromboembolism in ESRD. The direct oral anticoagulants (DOACs) apixaban and rivaroxaban have now permissive labeling in the United States for atrial fibrillation in patients with ESRD; this expanded labeling has not yet occurred either in Europe or for venous thromboembolism. This review summarizes the current evidence for the pharmacology of DOACs in ESRD as well as their utilization and safety in patients with ESRD and atrial fibrillation.
Tagalakis et al. (2018) studied this question.