Comparable Outcomes Using Low-Dose Apixaban and Anti-Xa Monitoring and Vitamin-K Antagonists in Patients with Renal Replacement Therapy

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Background: Guidelines recommend the use of oral anticoagulation for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism. Outside the USA, apixaban is contraindicated for use in patients with end stage renal disease (ESRD) receiving renal replacement therapy (RRT). Aim: To compare thrombotic and safety outcomes in patients receiving either vitamin-K antagonists (VKA) or apixaban 2.5mg twice daily in the context ESRD and RRT. Method: Retrospective service evaluation comparing bleeding and thrombotic outcomes in patients treated with apixaban 2.5mg BD or VKA in a tertiary anticoagulation clinic. Trough anti-Xa levels of apixaban patients were also reviewed. Clinical features and the outcomes were reviewed using electronic patient records. Results: 55 VKA and 33 apixaban patients were included in the analysis. There were no major bleeds in the apixaban cohort compared to 4 (7.3%) with VKA (χ 2=2.667, p=0.102). No difference in time to major or clinically relevant non-major bleeding (CRNMB) was found (χ 2=1.252 p=0.263). Rates of thrombotic events were 1 vs 3 (1.1 and 7.1 events/ 100 patient years) for VKA and apixaban respectively. 84 of 85 trough anti-Xa levels analysed were below the upper limit of normal of the reference range for the general population. Discussion: Our results demonstrate similar safety and thrombotic outcomes with VKA and apixaban in those receiving RRT indicating apixaban may be a viable second line treatment option in those for whom VKA may not be appropriate. Further investigation into the safety of the apixaban 5mg regimen is warranted.

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