Relative Risk Reductions in Stroke or Systemic Embolism and Major Hemorrhage by Novel Oral Anticoagulants vs. Warfarin in Patients With Moderate CKD
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Authors: Gautam R. Shroff, MBBS, FACC; Sarah E. Thordsen, MD; Charles A. Herzog, MD, FACC. The management of atrial fibrillation (AF) in advanced chronic kidney disease (CKD) is extremely complex due to the need to carefully balance the high risks of stroke versus hemorrhagic complications. Some have likened this clinical dilemma to navigating the waters between the mythical sea monsters Scylla and Charybdis.1 Certainly, the first step for clinicians should be a very thorough vetting of thromboembolic and hemorrhagic risk factors for an individual patient. We believe in involving the patient in this decision-making, this discussion with the patient should include disclosure regarding lack of a readily available reversal agent in case of bleeding with novel oral anticoagulants (NOACs). Among patients with CKD stage 3, there is a greater degree of choice now available beyond warfarin alone to assist in making an individualized and "patient-centered" decision.
For advanced CKD patients with a higher anticipated bleeding risk, it would appear from the literature that the evidence would support the use of apixaban or edoxaban (with appropriate dose modification as necessary) by virtue of favorable reduction in major hemorrhage relative to warfarin. However, in patients with a lower bleeding risk where the primary clinical concern is reduction in stroke/systemic embolism, it would appear from the available evidence that the dose of dabigatran 150 mg twice daily may be superior to warfarin while maintaining an equivalent bleeding risk. Because renal function can be dynamic and influenced by various factors, regular monitoring and appropriate adjustment of the dose of NOACs would be prudent.
- Mannucci PM. Thromboprophylaxis in the oldest old with atrial fibrillation: between Scylla and Charybdis. Eur J Intern Med 2013;24:285-287.
Date: April 22, 2015
Permission Attribution: Modified from Hart RG, Eikelboom JW, Ingram AJ, Herzog CA. Anticoagulants in atrial fibrillation patients with chronic kidney disease. Nat Rev Nephrol 2012;8:569-78.
Keywords: Anticoagulants, Atrial Fibrillation, Benzimidazoles, Disclosure, Embolism, Humans, Pyrazoles, Pyridines, Pyridones, Renal Insufficiency, Chronic, Risk, Risk Factors, Stroke, Thiazoles, Virtues, Warfarin, beta-Alanine, Geriatrics