1
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Firth C, Shamoun F, Apolinario M, Lim ES, Zhang N, Keddis MT. Safety and mortality outcomes for direct oral anticoagulants in renal transplant recipients. PLoS One 2023; 18:e0285412. [PMID: 37192210 DOI: 10.1371/journal.pone.0285412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 04/20/2023] [Indexed: 05/18/2023] Open
Abstract
PURPOSE Direct oral anticoagulants (DOACs) are increasingly used in renal transplant recipients (RTR), but relatively understudied in this population. We assess the safety of post-transplant anticoagulation with DOACs compared to warfarin. METHODS We conducted a retrospective study of RTRs at the Mayo Clinic sites (2011-present) that were anticoagulated for greater than 3 months excluding the 1st month post-transplant. The main safety outcomes were bleeding and all-cause mortality. Concomitant antiplatelet and interacting drugs were noted. DOAC dose adjustment was assessed according to common US prescribing practices, guidelines, and/or FDA labeling. RESULTS The median follow-up was longer for RTRs on warfarin (1098 days [IQR 521, 1517]) than DOACs (449 days [IQR 338, 942]). Largely, there were no differences in baseline characteristics and comorbidities between RTRs on DOACs (n = 208; apixaban 91.3%, rivaroxaban 8.7%) versus warfarin (n = 320). There was no difference in post-transplant use of antiplatelets, immunosuppressants, most antifungals assessed, or amiodarone. There was no significant difference in incident major bleeding (8.4 vs. 5.3%, p = 0.89), GI bleeding (4.4% vs. 1.9%, p = 0.98), or intra-cranial hemorrhage (1.9% vs. 1.4%, p = 0.85) between warfarin and DOAC. There was no significant difference in mortality in the warfarin group compared to DOACs when adjusted for follow-up time (22.2% vs. 10.1%, p = 0.21). Rates of post-transplant venous thromboembolism, atrial fibrillation or stroke were similar between the two groups. 32% (n = 67) of patients on DOACs were dose reduced, where 51% of those reductions were warranted. 7% of patients that were not dose reduced should have been. CONCLUSIONS DOACs did not have inferior bleeding or mortality outcomes compared to warfarin in RTRs. There was greater use of warfarin compared to DOACs and a high rate of improper DOAC dose reduction.
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Affiliation(s)
- Christine Firth
- Department of Cardiovascular Diseases, Scottsdale, AZ, United States of America
| | - Fadi Shamoun
- Department of Cardiovascular Diseases, Scottsdale, AZ, United States of America
| | - Michael Apolinario
- Department of Internal Medicine, Scottsdale, AZ, United States of America
| | - Elisabeth S Lim
- Department of Quantitative Health Sciences, Scottsdale, AZ, United States of America
| | - Nan Zhang
- Department of Quantitative Health Sciences, Scottsdale, AZ, United States of America
| | - Mira T Keddis
- Department of Nephrology, Mayo Clinic, Scottsdale, AZ, United States of America
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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3
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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4
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A Review of Direct-acting Oral Anticoagulants and Their Use in Solid Organ Transplantation. Transplantation 2022; 106:2143-2154. [PMID: 35642975 DOI: 10.1097/tp.0000000000004195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Direct-acting oral anticoagulant (DOAC) use has increased dramatically since their introduction because of the growing evidence of proven efficacy and enhanced safety compared with warfarin and the low-molecular-weight heparins in the general population. Unfortunately, there is a dearth of quality data regarding the safety and efficacy of the DOACs in patients awaiting organ transplant and those who received a solid organ transplant. This review aims to evaluate the available literature and considerations regarding anticoagulation use in transplant recipients, focusing on preoperative, perioperative, and postoperative DOAC use.
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5
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Zaitoun MF, Sheikh ME, Faifi ASA, Mahedy AW, Nazer WE, El Hennawy HM. The Use of Non-Vitamin K Antagonist Oral Anticoagulants in Post-Kidney Transplantation, Single-Center Experience. Transplant Proc 2021; 53:2918-2922. [PMID: 34772494 DOI: 10.1016/j.transproceed.2021.09.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/30/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Novel oral anticoagulants (NOACs) are widely used alternatives to warfarin, because they do not require routine monitoring and have better safety profile. There is limited experience for NOACs in organ transplant recipients. METHODS This study assessed NOAC safety and efficacy among renal transplant recipients in a single center. A retrospective matched cohort study was conducted among the adult renal transplant recipients concomitantly administered calcineurin inhibitors (tacrolimus or cyclosporin) and NOACs between November 2015 and December 2019. RESULTS The study included 16 patients divided into 2 equal groups on NOACs and warfarin. Male patients constitute 50% and 75% of the NOAC group and warfarin group, respectively, and 75% and 87.5% of cases are post living donor transplants in the NOAC group and warfarin group, respectively. In the NOAC group, the most common indication for anticoagulation was atrial fibrillation (62.5%), followed by deep vein thrombosis (37.5%), whereas in the warfarin group, the most common indication was atrial fibrillation (50%), followed by valve replacement (25%). In the NOAC group, 6 patients (75%) received rivaroxaban, 1 patient (12.5%) received dabigatran, and 1 patient (12.5%) received apixaban; 68.75% of patients were on a tacrolimus-based regimen. There were no thromboembolic events, rejection episodes, bleeding, or admissions due to NOAC adverse events. There were 3 cases of bleeding in the warfarin group. Calcineurin inhibitor levels and estimated glomerular filtration rate did not change significantly in the NOAC group (P = .34 and .96, respectively). CONCLUSIONS Compared to warfarin, NOACs are well tolerated and effective for preventing and treating thromboembolic events in renal transplant recipients. A larger randomized controlled study is required.
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Affiliation(s)
- Mohammad F Zaitoun
- Pharmaceutical Care Services, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Kingdom of Saudi Arabia
| | - Mahmoud El Sheikh
- Pharmaceutical Care Services, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Kingdom of Saudi Arabia
| | - Abdullah S Al Faifi
- Transplant Surgery Section, Surgery Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Kingdom of Saudi Arabia
| | - Ahmed W Mahedy
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Kingdom of Saudi Arabia; Internal Medicine Department, Faculty of Medicine, Benah University, Egypt
| | - Weam El Nazer
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Kingdom of Saudi Arabia
| | - Hany M El Hennawy
- Transplant Surgery Section, Surgery Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Kingdom of Saudi Arabia.
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6
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Green H, Rahamimov R, Spectre G, Rozen-Zvi B, Fuchs S, Avni S, Nissan R. Apixaban Level and Its Influence on Immunosuppression and Graft Outcome in Kidney Transplant Recipients With Atrial Fibrillation. Ther Drug Monit 2021; 43:637-644. [PMID: 33337589 DOI: 10.1097/ftd.0000000000000858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Currently, there is limited information on the level of apixaban in kidney transplant (KT) patients with atrial fibrillation and the influence of apixaban therapy on the level of immunosuppression and graft function. METHODS This was a cross-sectional prospective study of 19 KT patients treated with apixaban. The levels of apixaban were measured using a chromogenic assay calibrated for apixaban and compared with those predicted by the manufacturer. Mean immunosuppression trough levels before and after apixaban treatment initiation were calculated using 3 consecutive measurements. Apixaban levels were compared with a historical control group comprising of 20 nontransplant patients with atrial fibrillation who were treated with the standard 5-mg bid apixaban dosage. RESULTS All KT patients should have been treated with the standard 5-mg bid apixaban dosage according to the clinical parameters; however, 7 were inappropriately treated with a reduced dosage (2.5-mg bid). There was no significant difference in apixaban level between KT patients treated with the 5-mg bid dosage and nontransplant patients. No KT patient administered the standard dose had out-of-range levels. Peak GM level was significantly lower in KT patients administered an inappropriately reduced dose (P = 0.05). Two patients had below-range peak levels. Apixaban treatment initiation had minimal influence on the level of immunosuppression. Furthermore, it had no adverse impact on graft function. CONCLUSIONS Similar to nontransplant patients, KT patients administered the standard 5-mg bid dosage had apixaban levels that were well within the recommended manufacturers' expected ranges. In addition, this dosage had minimal influence on immunosuppression and no effect on graft function.
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Affiliation(s)
- Hefziba Green
- Department of Medicine B, Rabin Medical Center
- Institute of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva
- Sackler School of Medicine, Tel-Aviv University, Tel-aviv
| | - Ruth Rahamimov
- Institute of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva
- Sackler School of Medicine, Tel-Aviv University, Tel-aviv
| | - Galia Spectre
- Sackler School of Medicine, Tel-Aviv University, Tel-aviv
- Coagulation Unit, Institute of Hematology, Rabin Medical Center, Petah-Tikva
| | - Benaya Rozen-Zvi
- Institute of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva
- Sackler School of Medicine, Tel-Aviv University, Tel-aviv
| | - Shmuel Fuchs
- Sackler School of Medicine, Tel-Aviv University, Tel-aviv
- Cardiology Institute, Assaf Harofe Medical Center, Zrifin; and
| | - Shiri Avni
- Department of Medicine B, Rabin Medical Center
| | - Ran Nissan
- Department of Medicine B, Rabin Medical Center
- Pharmacy Services, Rabin Medical Center, Petah-Tikva, Israel
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7
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Parker K, Chu J, Morton M, Bhutani S, Picton M, Mitra S, Thachil J. Can direct oral anticoagulants be used in kidney transplant recipients? Clin Transplant 2021; 35:e14474. [PMID: 34498777 DOI: 10.1111/ctr.14474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/10/2021] [Accepted: 09/01/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Kidney transplant recipients(KTRs) are at an increased risk of venous thromboembolism (VTE) and atrial fibrillation(AF). Direct oral anticoagulants (DOACs) have shown important advantages over vitamin K antagonists; however, in KTRs, concerns regarding interactions and use in severe kidney disease may limit their use. This evaluation describes a large UK kidney transplant center's experience of DOACs in KTRs with CrCl > 15 mL/min. METHODS Electronic records were reviewed for all adult KTRs at Manchester University Foundation Trust Hospitals taking DOACs between January 2018 and October 2020 with VTE or AF. The primary outcome was trough and peak DOAC levels within the expected reference ranges and secondary outcomes included bleeding and thrombotic events. RESULTS In 31 KTRs taking DOACS, eight patients had a CrCl < 30 mL/min. Overall, 94% (62/66) of DOAC levels were within the recommended ranges. There were no thrombotic events and four bleeding events (two major and two clinically relevant non-major bleeds). The overall bleeding rate was 6.9 per 100 patient-years at risk. CONCLUSIONS There was no evidence of a significant interaction of apixaban or rivaroxaban with CNIs based on expected DOAC and CNI levels. Their use was found to be safe and effective with no VTE events and bleeding episodes similar to published trial data.
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Affiliation(s)
- Kathrine Parker
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK.,Division of Pharmacy and Optometry, School of Health Sciences, Academic Health Science Centre, University of Manchester, Manchester, The University of Manchester, Manchester, UK
| | - Janette Chu
- Department of Pharmacy, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Muir Morton
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Shiv Bhutani
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Michael Picton
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Sandip Mitra
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK.,The University of Manchester, Division of Cardiovascular Sciences, School of Medical Sciences, Manchester, UK
| | - Jecko Thachil
- Department of Haematology, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
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8
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Pfrepper C, Herber A, Weimann A, Siegemund R, Engelmann C, Aehling N, Seehofer D, Berg T, Petros S. Safety and efficacy of direct oral anticoagulants under long-term immunosuppressive therapy after liver, kidney and pancreas transplantation. Transpl Int 2021; 34:423-435. [PMID: 33336411 DOI: 10.1111/tri.13804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/19/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022]
Abstract
The safety of direct oral anticoagulants (DOACs) in patients after solid organ transplantation (SOT) is not well defined. This study aimed at describing the safety and efficacy of DOACs in patients after SOT. Patients after kidney and/or liver transplantation under maintenance immunosuppression treated with rivaroxaban (n = 26), apixaban (n = 20) and edoxaban (n = 1) were included. Clinical data were collected retrospectively and using a questionnaire. DOAC plasma levels and thrombin generation (TG) were measured in patients after SOT and compared with nontransplanted controls receiving DOACs. DOACs were administered for 84.6 patient-years. Mean immunosuppressive trough levels after DOAC initiation increased from baseline by 18.8 ± 29.6% compared to 3.0 ± 16.5% in matched controls (P = 0.004), without significant differences in dose adjustments. No transplant rejection or significant change in liver or renal function was observed. There was one major bleeding after the observation period but no thromboembolic complication. DOAC plasma levels reached the expected range in all patients. The intrinsic hemostatic activity in transplanted patients was higher compared to nontransplant controls. Treatment with DOACs after SOT is safe and effective. Immunosuppressive trough levels should be monitored after DOAC initiation, particularly in the early phase after SOT. These data should be confirmed in a prospective study.
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Affiliation(s)
- Christian Pfrepper
- Division of Hemostaseology, Department of Medicine I, University Hospital Leipzig, Leipzig, Germany
| | - Adam Herber
- Division of Hepatology, Department of Medicine II, University Hospital Leipzig, Leipzig, Germany
| | - Antje Weimann
- Department of Visceral, Vascular, Thoracic and Transplant Surgery, University Hospital Leipzig, Leipzig, Germany
| | | | - Cornelius Engelmann
- Division of Hepatology, Department of Medicine II, University Hospital Leipzig, Leipzig, Germany.,Institute for Liver and Digestive Health, University College London, London, UK.,Medical Department, Division of Hepatology and Gastroenterology, Charite - Universitätsmedizin Berlin, Berlin, Germany
| | - Niklas Aehling
- Division of Hepatology, Department of Medicine II, University Hospital Leipzig, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Vascular, Thoracic and Transplant Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Thomas Berg
- Division of Hepatology, Department of Medicine II, University Hospital Leipzig, Leipzig, Germany
| | - Sirak Petros
- Division of Hemostaseology, Department of Medicine I, University Hospital Leipzig, Leipzig, Germany.,Medical ICU, University Hospital Leipzig, Leipzig, Germany
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9
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Salerno DM, Thornberg ME, Lange NW, Hedvat J, Robbins H, Brown RS, Jennings D, Scheffert J. Less bleeding associated with apixaban versus other direct acting oral anticoagulation in solid organ transplant recipients. Clin Transplant 2021; 35:e14396. [PMID: 34165845 DOI: 10.1111/ctr.14396] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/19/2021] [Accepted: 06/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate outcomes of bleeding and thrombosis resulting from the use of DOACs in a large cohort of SOT recipients. METHODS This was a single center, retrospective cohort study of adult kidney, heart, lung, and liver transplant recipients transplanted between August 2009 and May 2018. Patients were stratified into two groups: those who received apixaban (apixaban group) or those patients receiving either rivaroxaban or dabigatran (non-apixaban group). The primary endpoint was the cumulative incidence of bleeding while receiving DOAC therapy. The secondary endpoints were incidence of major bleeding and thrombosis at any time while receiving DOAC therapy. RESULTS A total of 106 patients were included; 70 patients received apixaban and 36 patients received non-apixaban anticoagulation. Cumulative incidence of any bleeding was lower in the apixaban group compared to the non-apixaban group at both 90 days (4.9% versus 16.1%) and 180 days (11.4% versus 24.9%, P = 0.034). Cumulative incidence of major bleeding (P = 0.686) and thrombosis (P = 0.515) were similar between groups. DOAC dosing congruent with the package insert(s) was associated with a lower risk of thrombosis. CONCLUSION Apixaban-based anticoagulation was associated with a lower cumulative incidence of any bleeding compared to non-apixaban DOACs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, 10065, USA
| | - Megan E Thornberg
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, 10065, USA
| | - Nicholas W Lange
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, 10065, USA
| | - Jessica Hedvat
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, 10065, USA
| | - Hilary Robbins
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, 10032, USA
| | - Robert S Brown
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, 10065, USA
| | - Douglas Jennings
- Long Island University Department of Pharmacy Practice, New York, 11201, USA
| | - Jenna Scheffert
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, 10065, USA
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10
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Scheibner AC, Franco-Martinez C, Kincaide E, Hall R, Long C. The Impact of Rivaroxaban and Apixaban on Tacrolimus Trough Levels. Prog Transplant 2021; 31:236-241. [PMID: 34155947 DOI: 10.1177/15269248211024601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The solid organ transplant community is slow to adopt the routine practice of using direct oral anticoagulants. Rivaroxaban and apixaban share common metabolic pathways with tacrolimus. This study aimed to clarify the impact of rivaroxaban/apixaban on tacrolimus troughs. Fifty solid organ transplant recipients with concomitant use of tacrolimus and rivaroxaban/apixaban were retrospectively assessed for changes in tacrolimus troughs and dose. Average dose-adjusted tacrolimus troughs and average tacrolimus total daily doses prior to and after rivaroxaban/apixaban initiation were compared. Subgroup analyses evaluating rivaroxaban and apixaban individually were performed. Rivaroxaban was prescribed to 18 recipients, and apixaban was prescribed to 32 recipients. Transplanted organs included kidney (n = 22), lung (n = 18), liver (n = 7), simultaneous pancreas and kidney (n = 1), and simultaneous kidney and liver (n = 2). The median doseadjusted tacrolimus trough and tacrolimus total daily dose prior to rivaroxaban/apixaban initiation was 2.15 ng/mL/mg (IQR 1.17, 3.37) and 4 mg (IQR 1.88, 6.25), respectively. The median dose-adjusted tacrolimus trough and tacrolimus total daily dose after rivaroxaban/apixaban initiation was 2.16 ng/mL/mg (IQR 1.24, 4.10) and 3.55 mg (IQR 1.5, 6.35), respectively. No significant difference was found between average dose-adjusted tacrolimus troughs or tacrolimus total daily doses before and after rivaroxaban/apixaban initiation or in the individual subgroup analyses for rivaroxaban/apixaban. It is unlikely that initiating rivaroxaban/apixaban affects tacrolimus troughs or requires tacrolimus dose adjustment. This study does not elucidate if tacrolimus affects rivaroxaban/apixaban pharmacokinetics or pharmacodynamics.
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Affiliation(s)
- Aileen C Scheibner
- Department of Pharmacotherapy Services, 43159University Health System, San Antonio, TX, USA.,Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, TX, USA.,University of Texas Health San Antonio, San Antonio, TX, USA
| | - Crystal Franco-Martinez
- Department of Pharmacotherapy Services, 43159University Health System, San Antonio, TX, USA.,Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, TX, USA.,University of Texas Health San Antonio, San Antonio, TX, USA
| | - Elisabeth Kincaide
- Department of Pharmacotherapy Services, 43159University Health System, San Antonio, TX, USA.,Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, TX, USA.,University of Texas Health San Antonio, San Antonio, TX, USA
| | - Reed Hall
- Department of Pharmacotherapy Services, 43159University Health System, San Antonio, TX, USA.,Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, TX, USA.,University of Texas Health San Antonio, San Antonio, TX, USA.,Pharmacotherapy Education & Research Center, School of Medicine, University of Texas Health San Antonio, TX, USA
| | - Christina Long
- Department of Pharmacotherapy Services, 43159University Health System, San Antonio, TX, USA.,University of Texas Health San Antonio, San Antonio, TX, USA.,Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
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11
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Vio R, Proietti R, Rigato M, Calò LA. Clinical Evidence for the Choice of the Direct Oral Anticoagulant in Patients with Atrial Fibrillation According to Creatinine Clearance. Pharmaceuticals (Basel) 2021; 14:ph14030279. [PMID: 33808739 PMCID: PMC8003529 DOI: 10.3390/ph14030279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022] Open
Abstract
Atrial fibrillation (AF) often coexists with chronic kidney disease (CKD), which confer to the patient a higher risk of both thromboembolic and hemorrhagic events. Oral anticoagulation therapy, nowadays preferably with direct oral anticoagulants (DOACs), represents the cornerstone for ischemic stroke prevention in high-risk patients. However, all four available DOACs (dabigatran, apixaban, rivaroxaban and edoxaban) are eliminated by the kidneys to some extent. Reduced kidney function facilitates DOACs accumulation and, therefore, different dose reductions are required, with slight differences between American and European recommendations especially in case of severe renal impairment (creatinine clearance < 30 mL/min). Overall, the use of DOACs in patients with non-end stage CKD and AF is effective similarly to warfarin, showing a better safety profile. The management of thromboembolic risk among patients with AF on dialysis remains challenging, as warfarin effectiveness for stroke prevention in this population is questionable and retrospective data on apixaban need to be confirmed on a larger scale. In kidney transplant recipients, DOACs may provide a potentially safer option compared to warfarin, but co-administration with immunosuppressants is a matter of concern.
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Affiliation(s)
- Riccardo Vio
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Riccardo Proietti
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Matteo Rigato
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, 35128 Padova, Italy
| | - Lorenzo Arcangelo Calò
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, 35128 Padova, Italy
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12
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Kao CC, Wang T, Parulekar AD. Need for anticoagulation and use of direct oral anticoagulants in lung transplant recipients. J Thromb Thrombolysis 2021; 52:232-238. [PMID: 33661478 DOI: 10.1007/s11239-021-02399-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/29/2022]
Abstract
Limited information is available about use of direct oral anticoagulants (DOACs) in lung transplant recipients (LTRs). The purpose of this study is to describe the indications and use of long-term anticoagulation, including the safety and tolerability of DOACs, in LTRs. This was a single-center retrospective study. LTRs who received therapeutic anticoagulation were identified. Patient characteristics, indications for treatment, and complications of therapy were obtained. A total of 203 patients underwent lung transplantation of which 118 patients (58.1%) had an indication for anticoagulation. Patients with an indication for anticoagulation were older than those without (59 ± 14 years versus 48 ± 17 years, p < 0.001) and were more likely to be male (72.0% versus 50.6%, p = 0.002). Of the patients with indication for anticoagulation, 74 (62.7%) received it. Fifty-one (68.9%) of patients receiving anticoagulation were treated with DOACs. In the patients receiving anticoagulation, there were 14 major bleeding events in 13 patients, of which 3 were receiving DOACs and the remainder were receiving heparin or warfarin. The need for anticoagulation is common in LTRs for both atrial arrhythmias and venous thromboembolism. However, many patients with atrial arrhythmias do not receive anticoagulation. The use of DOACs is well tolerated and safe in LTRs.
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Affiliation(s)
- Christina C Kao
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Tai Wang
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Amit D Parulekar
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA. .,Vanderbilt University Medical Center, 1161 21st Ave South, T1218 MCN, Nashville, TN, 37232, USA.
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13
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García-Ortega A, López-Reyes R, Anguera G, Oscullo G, Rivas A, López-Jiménez L, Lorenzo A, Mahé I, Ciammaichella M, Monreal M. Venous thromboembolism in solid-organ transplant recipients: Findings from the RIETE registry. Thromb Res 2021; 201:131-138. [PMID: 33684796 DOI: 10.1016/j.thromres.2021.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/27/2021] [Accepted: 02/18/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) represents a relevant cause of morbidity in patients with solid-organ transplant (SOT), but there are scarce data on the management and outcomes in these patients. METHODS RIETE is a worldwide, ongoing observational registry of patients with objectively confirmed, acute VTE. We used the RIETE database to compare the clinical characteristics, treatment and outcomes in SOT recipients vs. non-recipients. RESULTS From January 2001 to December 2019, 83,210 patients were enrolled in RIETE. Of these, 329 (0.4%) were SOT recipients: in the kidney 221, liver 41, lung 28 and heart 25. Median duration of anticoagulation was similar in SOT recipients and non-recipients (174 vs. 182 days). During anticoagulation, 1180 patients developed deep vein thrombosis (DVT) recurrences, 1028 pulmonary embolism (PE) recurrences, 2392 had major bleeding, 3119 non-major bleeding and 8157 died. SOT recipients had a higher rate of major bleeding (hazard ratio [HR]: 2.55; 95% CI: 1.62-3.84) and clinically relevant non-major bleeding (HR: 1.94; 95% CI: 1.23-2.93) than non-recipients, with no differences in the rates of DVT recurrences (HR: 0.96; 95% CI: 0.30-2.32), PE recurrences (HR: 1.11; 95% CI: 0.35-2.67) or death (HR: 0.98; 95% CI: 0.67-1.40). On multivariable analysis, only liver transplant recipients were at an increased risk for major bleeding compared to non-recipients (adjusted HR: 3.17; 95% CI: 1.02-9.87). CONCLUSIONS Treatment of VTE in SOT recipients is associated with an increased risk of bleeding compared to non-recipients. This is mainly due to the influence of liver transplant recipients. In non-liver SOT recipients, the risk for bleeding was similar to that in non-recipients.
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Affiliation(s)
- Alberto García-Ortega
- Respiratory Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Lung Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Medical Research Institute Hospital La Fe (IISLAFE), Valencia, Spain.
| | - Raquel López-Reyes
- Respiratory Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Gabriel Anguera
- Lung Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Grace Oscullo
- Respiratory Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Agustina Rivas
- Department of Pneumonology, Hospital Universitario Araba, Álava, Spain
| | | | - Alicia Lorenzo
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - Isabelle Mahé
- Department of Internal Medicine, Hôpital Louis Mourier, Colombes (APHP), University Paris 7. France
| | | | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol. Badalona, Barcelona, Universidad Autónoma de Barcelona, Spain
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14
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Bixby AL, Lichvar AB, Salerno D, Park JM. Use of direct-acting oral anticoagulants in solid organ transplantation: A systematic review. Pharmacotherapy 2020; 41:28-43. [PMID: 33155327 DOI: 10.1002/phar.2485] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022]
Abstract
The use of direct-acting oral anticoagulants (DOACs) has increased secondary to the mounting evidence for comparable efficacy and potentially superior safety to vitamin K antagonists (VKAs) in the general population. However, insufficient data regarding DOAC use in solid organ transplant (SOT) recipients and numerous pharmacokinetic and pharmacodynamic considerations limit their use in this highly selected patient population. A systematic review of recent clinical evidence on the safety and efficacy of DOACs compared to VKAs in SOT recipients was conducted. Additional considerations including transplant-specific strategies for DOAC reversal and common pharmacokinetic/pharmacodynamic concerns were also reviewed. Although current evidence is limited to single-center retrospective analyses, DOACs, especially apixaban, appear to be a safe and effective alternative to VKAs for SOT recipients with stable graft function and without drug-drug interactions. Reliable data on DOAC reversal at the time of transplant surgery are lacking, and clinicians should consider idarucizumab, andexanet alfa, and other non-specific reversal agents on an individual patient basis. There is no evidence supporting deviations from the Food and Drug Administration labeling recommendations for DOAC dosing in the setting of drug-drug interactions, obesity, and renal function, especially in patients on hemodialysis.
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Affiliation(s)
- Alexandra L Bixby
- Department of Pharmacy Services, University of Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Alicia B Lichvar
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA.,Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - David Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
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15
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Su X, Zhao X, Long DY, Sang CH, Yu RH, Tang RB, Bai R, Liu N, Jiang CX, Li SN, Guo XY, Wang W, Hu R, Du X, Dong JZ, Ma CS. Safety and efficacy of catheter ablation for atrial fibrillation in abdominal solid organ (renal and hepatic) transplant recipients: A single-center pilot experience. J Cardiovasc Electrophysiol 2020; 31:3141-3149. [PMID: 33051930 DOI: 10.1111/jce.14775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/15/2020] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is common in abdominal solid organ transplant recipients and a cause of morbidity and mortality in this population. However, the outcomes of catheter ablation (CA) in transplant recipients with AF remain unclear. This study aimed to elucidate the outcomes of CA in renal and hepatic transplant recipients. METHODS AND RESULTS Between 2015 and 2019, 14 transplant recipients (nine with kidney transplantation and five with liver transplantation) were enrolled from among 10,741 AF patients and underwent CA at Anzhen Hospital. Another 56 patients matched by age, sex, and AF type were selected as the control group (four controls for each transplant recipient). During a mean follow-up of 30.0 ± 13.3 months after the initial procedure, 10 (71.4%) of the transplant patients, compared to 41 (73.2%) of the control patients, remained free from AF recurrence (p = 1.000). A repeated procedure was performed in one transplant patient and in six control subjects. Consequently, 11 (78.6%) of the transplant patients, compared to 46 (82.1%) of controls, were in sinus rhythm after the repeated ablation (p = .715). Notably, Kaplan-Meier analysis did not demonstrate any significant differences in the atrial arrhythmia-free rate after the initial and repeated procedure between the two groups. Vascular complications were identified in one transplant patient and two control subjects, while no life-threatening complications were observed in either group. There was no transient allograft dysfunction in transplant recipients after CA. CONCLUSION CA is safe and effective in abdominal solid transplant recipients, and maybe an optimal therapeutic strategy for this group.
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Affiliation(s)
- Xin Su
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - De-Yong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Cai-Hua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Rong-Hui Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ri-Bo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Rong Bai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chen-Xi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Song-Nan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xue-Yuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wei Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Rong Hu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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16
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Degraeve AL, Moudio S, Haufroid V, Chaib Eddour D, Mourad M, Bindels LB, Elens L. Predictors of tacrolimus pharmacokinetic variability: current evidences and future perspectives. Expert Opin Drug Metab Toxicol 2020; 16:769-782. [PMID: 32721175 DOI: 10.1080/17425255.2020.1803277] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION In kidney transplantation, tacrolimus (TAC) is at the cornerstone of current immunosuppressive strategies. Though because of its narrow therapeutic index, it is critical to ensure that TAC levels are maintained within this sharp window through reactive adjustments. This would allow maximizing efficiency while limiting drug-associated toxicity. However, TAC high intra- and inter-patient pharmacokinetic (PK) variability makes it more laborious to accurately predict the appropriate dosage required for a given patient. AREAS COVERED This review summarizes the state-of-the-art knowledge regarding drug interactions, demographic and pharmacogenetics factors as predictors of TAC PK. We provide a scoring index for each association to grade its relevance and we present practical recommendations, when possible for clinical practice. EXPERT OPINION The management of TAC concentration in transplanted kidney patients is as critical as it is challenging. Recommendations based on rigorous scientific evidences are lacking as knowledge of potential predictors remains limited outside of DDIs. Awareness of these limitations should pave the way for studies looking at demographic and pharmacogenetic factors as well as gut microbiota composition in order to promote tailored treatment plans. Therapeutic approaches considering patients' clinical singularities may help allowing to maintain appropriate concentration of TAC.
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Affiliation(s)
- Alexandra L Degraeve
- Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium.,Metabolism and Nutrition Research Group (Mnut), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium
| | - Serge Moudio
- Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium.,Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut De Recherche Expérimentale Et Clinique (IREC), Université Catholique De Louvain , Brussels, Belgium
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut De Recherche Expérimentale Et Clinique (IREC), Université Catholique De Louvain , Brussels, Belgium.,Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Djamila Chaib Eddour
- Kidney and Pancreas Transplantation Unit, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Michel Mourad
- Kidney and Pancreas Transplantation Unit, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Laure B Bindels
- Metabolism and Nutrition Research Group (Mnut), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium
| | - Laure Elens
- Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium.,Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut De Recherche Expérimentale Et Clinique (IREC), Université Catholique De Louvain , Brussels, Belgium
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17
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Novel Oral Anticoagulants in Renal Transplant Recipients: A Retrospective Cohort Study. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2020; 41:49-55. [PMID: 33011699 DOI: 10.2478/prilozi-2020-0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM Data on the use of novel anticoagulant drugs (NOACc) in renal transplant recipients is scarce. The aim of our study was to investigate the safety and efficacy of NOACs in renal transplant recipients. MATERIALS AND METHODS In a single-centre retrospective cohort study we assessed adverse reactions, thromboembolic events, and interactions of calcineurin inhibitors in patients treated with NOACs. RESULTS Twenty-three renal transplant recipients were treated with NOACs (70% male), mean age of 65.8 ± 1.8 years. Fourteen (61%) patients were treated with rivaroxaban, apixaban was given to 8 (35%) of our patients, and dabigatran to one patient (4%). The main indications for NOAC therapy was atrial fibrillation in 61% and deep venous thrombosis in 23% of patients. Bleeding occurred in 2 patients (1 treated with rivaroxaban and 1 with dabigatran). None of our patients developed thrombosis while treated with NOAC. During the median follow-up of 24 months graft function, as well as hematological parameters, remained stable in patients that were treated with rivaroxaban and apixaban, while dabigatran was ceased after a month of therapy due to a bleeding event. CONCLUSION Our results show that both rivaroxaban and apixaban are safe and efficient oral anticoagulant drugs in renal transplant patients. Additional studies are needed to prove these results.
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18
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Camporese G, Bernardi D, Bernardi E, Avruscio GP, Marchini F, Bonfante L, Furian L, Neri F, Villalta S, Fabris F, Simioni P, Sartori MT. Absence of interaction between rivaroxaban, tacrolimus and everolimus in renal transplant recipients with deep vein thrombosis or atrial fibrillation. Vascul Pharmacol 2020; 130:106682. [PMID: 32438078 DOI: 10.1016/j.vph.2020.106682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 02/24/2020] [Accepted: 05/08/2020] [Indexed: 01/03/2023]
Abstract
No data are available on rivaroxaban use in renal transplant recipients and on its surmised interaction with immunosuppressants. The aim was to investigate potential interactions between rivaroxaban and immunosuppressants in this setting. Renal transplant recipients with a stable renal function treated with rivaroxaban and tacrolimus with or without everolimus were investigated. All drugs and creatinine concentrations were determined daily for 2 weeks after the start of anticoagulation. Blood samples were drawn at 8.00 am and 3-4 h later for trough and peak concentrations, respectively. Bleeding and thrombotic events were recorded during a minimum follow-up of 6 months. In 8 renal transplant patients, rivaroxaban levels showed a predictable pharmacokinetic trend, both at Ctrough (30-61 μg/L) and at Cpeak (143-449 μg/L), with limited variability in the 25th-75th percentile range. Tacrolimus (Ctrough 3-13 μg/L; Cpeak 3-16 μg/L), everolimus (Ctrough 3-11 μg/L; Cpeak 5-17 μg/L) and creatinine concentrations were stable as well. Immunosuppressors variability before and after rivaroxaban were 30% and 30% for tacrolimus, 27% and 29% for everolimus, respectively, as well as 14% and 3% for creatinine. For rivaroxaban monitoring, the reference change value better performed in identifying significant variations of its concentration. No patient had bleeding or thrombotic events, worsening of renal graft function, and signs of immunosuppressants toxicity during a mean follow-up of 23 (9-28) months. In conclusion, rivaroxaban does not seem to interact with tacrolimus and everolimus in renal transplant recipients. Both anticoagulant and immunosuppressive effects seem warranted, without major bleeding complications and effect on the graft function.
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Affiliation(s)
- G Camporese
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy.
| | - D Bernardi
- Department of Laboratory Medicine, Padova University Hospital, Italy
| | - E Bernardi
- Department of Emergency and Accident Medicine, Conegliano Hospital, Italy
| | - G P Avruscio
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - F Marchini
- Division of Nephrology and Renal Transplantation, Padova University Hospital, Italy
| | - L Bonfante
- Division of Nephrology and Renal Transplantation, Padova University Hospital, Italy
| | - L Furian
- Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Italy
| | - F Neri
- Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Italy
| | - S Villalta
- Department of Internal Medicine, Internal Medicine AULSS2 Marca Trevigiana, Treviso Hospital, Italy
| | - F Fabris
- Department of Internal Medicine, Clinical Medicine 1, Padova University Hospital, Italy
| | - P Simioni
- Department of Internal Medicine, General Medicine Unit, Thrombotic and Haemorrhagic Disorders Unit, Padova University Hospital, Italy
| | - M T Sartori
- Department of Internal Medicine, Clinical Medicine 1, Padova University Hospital, Italy
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19
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Somaili M, Jeyakumar N, McArthur E, Ribic C, Sood MM, Harel Z, Molnar AO. Incidence of Direct Oral Anticoagulant Prescriptions in Kidney Transplant Recipients in Ontario, Canada. Transplant Proc 2020; 52:3144-3152. [PMID: 32402459 DOI: 10.1016/j.transproceed.2020.02.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/16/2020] [Accepted: 02/23/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Kidney transplant recipients (KTRs) are routinely excluded from direct oral anticoagulant (DOAC) trials. Given the lack of safety and efficacy data in this population, we examined real-world prescribing practices of DOACs in KTRs. METHODS We conducted a retrospective cohort study using linked administrative data sets in Ontario, Canada. All adult KTRs (n = 5580) from June 23, 2009, to March 31, 2017, were included. The primary outcomes were the first prescription for a DOAC or warfarin. Patients were censored on graft failure, death, or end of follow-up. RESULTS The mean age was 55 (SD, 14) years; 63% were male, and 65% had received a deceased donor kidney. Over a median follow-up of 5.5 and 4.7 years, 224 KTRs (4.0%) and 824 KTRs (14.8%) were prescribed DOACs and warfarin, respectively. The rates of DOAC and warfarin prescriptions were 8.1 and 32.6 per 1000 person-years, respectively. Older age, receipt of a kidney transplant in more recent years, and higher baseline estimated glomerular filtration rate were associated with DOAC prescription compared with warfarin. Patients with multiple comorbidities and a history of deep venous thromboembolism had a lower risk of DOAC prescription compared with warfarin. When examined by era, the incidence rate of both DOAC and warfarin prescriptions increased significantly over time. CONCLUSIONS Despite limited safety and efficacy data, DOACs are prescribed to KTRs. However, warfarin still remains more commonly prescribed in this selected patient population. Anticoagulant prescriptions overall are on the rise in KTRs. Further study is needed to determine the safety and efficacy of DOACs in KTRs.
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Affiliation(s)
- Mohammed Somaili
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Christine Ribic
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Manish M Sood
- ICES, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ziv Harel
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
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20
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Bixby AL, Shaikh SA, Naik AS, Cotiguala L, McMurry K, Samaniego‐Picota MD, Marshall VD, Park JM. Safety and efficacy of direct‐acting oral anticoagulants versus warfarin in kidney transplant recipients: a retrospective single‐center cohort study. Transpl Int 2020; 33:740-751. [DOI: 10.1111/tri.13599] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/24/2019] [Accepted: 02/24/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Alexandra L. Bixby
- Department of Pharmacy Services University Hospitals Cleveland Medical Center Cleveland OH USA
| | - Suhail A Shaikh
- Department of Transplant Surgery Keck Medical Center of USC University of Southern California Los Angeles CA USA
| | - Abhijit S. Naik
- Department of Internal Medicine Michigan Medicine Ann Arbor MI USA
| | - Laura Cotiguala
- Department of Pharmacy Services Michigan Medicine Ann Arbor MI USA
| | - Katie McMurry
- Department of Pharmacy Services Michigan Medicine Ann Arbor MI USA
| | | | - Vincent D. Marshall
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor MI USA
| | - Jeong M. Park
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor MI USA
- Department of Pharmacy Services Michigan Medicine Ann Arbor MI USA
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21
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Efficacy and Safety of Direct Oral Anticoagulants in Kidney Transplantation: A Single-center Pilot Experience. Transplantation 2020; 104:2625-2631. [DOI: 10.1097/tp.0000000000003168] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Rizk J, Mehra MR. Anticoagulation management strategies in heart transplantation. Prog Cardiovasc Dis 2020; 63:210-218. [PMID: 32035125 DOI: 10.1016/j.pcad.2020.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/03/2020] [Indexed: 12/19/2022]
Abstract
Anticoagulation before, during, and after heart transplantation (HT) presents unique challenges to clinicians. Bleeding and thrombotic morbidity continues to affect this patient population throughout all phases of the HT journey. Reversal is commonly required since patients are commonly bridged to HT with left ventricular assist devices, which require chronic anti platelet and anticoagulation. Caution must be exercised in patients requiring cardiopulmonary bypass during surgery who are at risk of complications from heparin induced thrombocytopenia. The reported incidence of venous thromboembolism following HT is high, particularly during the first post-HT year, most likely due to surgery, biopsies, specific immunosuppression (mTOR inhibitors) and immobilization. It is crucial to maintain long-term oral anticoagulation after the first venous thromboembolism event, especially when risk factors exist. A major issue, and one for which there remains considerable debate, is the optimal treatment of such complications, particularly upper extremity venous thrombosis. For both warfarin and the thrombin inhibitors or Factor Xa inhibitors, the clinician must determine potential drug interactions based on the HT drug regimen, and then develop a patient-specific management strategy.
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Affiliation(s)
- John Rizk
- Arizona State University, Edson College, Phoenix, AZ, United States of America
| | - Mandeep R Mehra
- Brigham and Women's Heart & Vascular Center and Harvard Medical School, Boston, MA, United States of America.
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23
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Rizk J, Mehra MR. WITHDRAWN: Anticoagulation management strategies in heart transplantation. Prog Cardiovasc Dis 2020:S0033-0620(20)30026-8. [PMID: 32014513 DOI: 10.1016/j.pcad.2020.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/29/2020] [Indexed: 11/22/2022]
Affiliation(s)
- John Rizk
- Arizona State University, Edson College, Phoenix, AZ, United States of America
| | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States of America.
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24
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Derebail VK, Rheault MN, Kerlin BA. Role of direct oral anticoagulants in patients with kidney disease. Kidney Int 2019; 97:664-675. [PMID: 32107019 DOI: 10.1016/j.kint.2019.11.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/13/2022]
Abstract
The anticoagulation field is experiencing a renaissance that began with regulatory approval of the direct thrombin inhibitor dabigatran, a direct oral anticoagulant (DOAC), in 2010. The DOAC medication class has rapidly evolved to include the additional approval of 4 direct factor Xa inhibitors. Commensurately, DOAC use has increased and collectively account for the majority of new anticoagulant prescriptions. Despite exclusion of patients with moderate-to-severe kidney disease from most pivotal DOAC trials, DOACs are increasingly used in this setting. An advantage of DOACs is similar or improved antithrombotic efficacy with less bleeding risk when compared with traditional agents. Several post hoc analyses, retrospective studies, claims data studies, and meta-analyses suggest that these benefits extend to patients with kidney disease. However, the lack of randomized controlled trial data in specific kidney disease settings, with their unique pathophysiology, should be a call to action for the kidney community to systematically study these agents, especially because early data suggest that DOACs may pose less risk of anticoagulant-related nephropathy than do vitamin K antagonists. Most DOACs are renally cleared and are significantly protein bound in circulation; thus, the pharmacokinetics of these drugs are influenced by reduced renal function and proteinuria. DOACs are susceptible to altered metabolism by P-glycoprotein inhibitors and inducers, including drugs commonly used for the management of kidney disease comorbidities. We summarize the currently available literature on DOAC use in kidney disease and illustrate knowledge gaps that represent important opportunities for prospective investigation.
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Affiliation(s)
- Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.
| | - Bryce A Kerlin
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's, Columbus, Ohio, USA; Division of Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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25
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Bukhari MA, Al-Theaby A, Tawhari M, Al-Shaggag A, Pyrke R, Gangji A, Treleaven D, Ribic C. Efficacy and safety of non-vitamin K antagonist oral anticoagulants post-kidney transplantation. World J Transplant 2019; 9:134-144. [PMID: 31750090 PMCID: PMC6851500 DOI: 10.5500/wjt.v9.i6.134] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/17/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Novel oral anticoagulants (NOACs) were developed as alternatives to vitamin K antagonists, primarily warfarin, as they do not require routine monitoring and have limited drug-drug and drug-food interactions. However, the efficacy and safety of these agents in kidney transplantation are not well studied.
AIM To assess the profile and safety of NOACs for patients who had kidney transplantation, and to provide recommendations and guidelines on therapeutic strategies in these patients.
METHODS This was a retrospective study carried out among adult patients who were actively on the following NOACs (apixaban, rivaroxaban or dabigatran) in our renal transplantation program from December 2015 to December 2016. The patients were identified primarily through electronic medical record system (patient data linkage). Data on the clinical and laboratory profile of the patients were retrieved and analyzed with SPSS 22.0.
RESULTS Complete data on 42 renal transplant patients were retrieved: 59.5% males, 90.5% were whites and 66.7% were older than 60 years old. The mean duration since renal transplantation of the patients was 8.8 ± 7.4 years. The most common risk factors for the development of end-stage renal disease in the subjects were hypertension (19.0%), polycystic kidney disease (19.0%), followed by diabetic nephropathy (16.7%) and chronic glomerulonephritis (16.7%). The main indications for NOACs use in the cohort were atrial fibrillation in 25 patients (59.5%) and venous thromboembolism in 10 patients (23.8%). Overall, 29 patients (69%) were treated with apixaban, 10 patients (23.8%) with rivaroxaban and 3 patients (7.14%) with dabigatran. No (0%) thromboembolic events were observed during the one-year period, but 3 (7.1%) bleeding events occurred in the cohort consisting of 1 patient treated with rivaroxaban 15 mg daily and 2 patients who received apixaban 2.5 mg twice daily. There were no significant changes in serum tacrolimus level three days after the initiation of NOACs among patients treated with tacrolimus (pre- and post-NOACs tacrolimus levels were 7.2516 and 7.8867 ng/mL, P = 0.55, respectively). Also, after one-year of treatment with NOACs there were no significant changes in the pre- and post-NOACs serum creatinine level (P = 0.772) and estimated glomerular filtration rates (P = 0.232).
CONCLUSION No thromboembolic events or significant changes in renal profile were observed in our cohort of kidney transplant recipients who were treated with NOACs for at least a year. However, a few bleeding events were observed. This calls for further well-planned randomized controlled trials to assess the efficacy and safety of NOACs among renal transplant recipients.
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Affiliation(s)
| | - Abdulrahman Al-Theaby
- Department of Transplantation, King Abdulaziz Medical City, Riyadh 11159, Saudi Arabia
| | - Mohammed Tawhari
- Department of Transplantation, King Abdulaziz Medical City, Riyadh 11159, Saudi Arabia
| | - Ali Al-Shaggag
- Department of Nephrology and Transplantation King Fahad Specialist Hospital, Dammam 15215, Saudi Arabia
| | - Ryan Pyrke
- Department of Nephrology, McMaster University, Hamilton, ON L8N 4A6, Canada
| | - Azim Gangji
- Department of Nephrology, McMaster University, Hamilton, ON L8N 4A6, Canada
| | - Darin Treleaven
- Department of Nephrology, McMaster University, Hamilton, ON L8N 4A6, Canada
| | - Christine Ribic
- Department of Nephrology, McMaster University, Hamilton, ON L8N 4A6, Canada
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Malyszko J, Lopatowska P, Mlodawska E, Musialowska D, Malyszko JS, Tomaszuk-Kazberuk A. Atrial fibrillation in kidney transplant recipients: is there a place for the novel drugs? Nephrol Dial Transplant 2019; 33:1304-1309. [PMID: 28992319 DOI: 10.1093/ndt/gfx265] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 07/15/2017] [Indexed: 01/06/2023] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia of high clinical importance, occurring in 2% of the general population and in 19-24% in patients with chronic kidney disease. It is a well-known risk factor for cardiovascular morbidity and mortality. Kidney transplant recipients with a history of AF were associated with significantly higher rate of ischaemic strokes, graft failure and post-transplant mortality. AF occurs in over 7% of kidney transplant recipients in the first 3 years after transplantation and is associated with reduced graft and patient survival. The incidence of stroke in patients after kidney transplantation (KTx) is higher than the general population, but markedly lower than those on dialysis. Oral anticoagulation (OAC) therapy is recommended in AF patients at high risk of stroke. There are no randomized studies assessing OAC in patients after KTx and there are no specific recommendations and guidelines on therapeutic strategies in these patients. KTx recipients are a vulnerable population, exposed to variations in renal function, being at higher risk of bleeding and thrombotic complications, with possible interactions with immunosuppression. Surely, there is a place for novel oral anticoagulants (NOACs) in this group of patients as long as the summary of product characteristics is followed, as they are a valuable anticoagulation therapy. On one hand, they are at least as effective as warfarin; on the other hand NOACs are safer, especially when it comes to intracranial haemorrhages. However, NOACs seem to be underused in this population as they are excreted via kidney, may interact with immunosuppressive therapy and physicians need more experience and confidence in their administration. Percutaneous left atrial appendage occlusion procedure may also be considered as an opportunity for this group of patients, in particular in the presence of contraindications to anticoagulation.
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Affiliation(s)
- Jolanta Malyszko
- 2nd Department of Nephrology and Hypertension with Dialysis Unit, Medical University, Bialystok, Poland
| | | | | | - Dominika Musialowska
- 2nd Department of Nephrology and Hypertension with Dialysis Unit, Medical University, Bialystok, Poland
| | - Jacek S Malyszko
- 1st Department of Nephrology and Transplantology with Dialysis Unit, Medical University, Bialystok, Poland
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Alsheikh R, Alfayez OM, Al Yami MS. Insights From Practice With Use of Direct Oral Anticoagulants in Transplantation. Prog Transplant 2018; 28:380-385. [DOI: 10.1177/1526924818800056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Solid organ transplant patients are at risk of developing atrial fibrillation and venous thromboembolism. Direct oral anticoagulants are considered an attractive option for anticoagulation in patients due to their convenience; however, strong evidence of their use in transplantation is lacking. We conducted a search using Pubmed, Embase, and Scopus databases, in addition to International Society of Heart and Lung transplantation and American Transplant Congress abstracts (from 2012 through December 2017). Fourteen articles were reviewed that included case reports, retrospective case series, or chart review analyses of small cohorts. Based on this review, the findings can only generate hypotheses that should be further studied in a larger randomized cohort. This review can help clinicians gain insight into the use of direct oral anticoagulant in this special population. For now, clinicians should be cautious about their use in this special population.
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Affiliation(s)
- Razan Alsheikh
- Department of clinical pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
- Department of pharmacy practice and science, University of Arizona, Tucson, AZ, USA
| | - Osamah M. Alfayez
- Department of pharmacy practice and science, University of Arizona, Tucson, AZ, USA
- Department of pharmacy practice, Qassim University, Qassim, Saudi Arabia
| | - Majed S. Al Yami
- Department of pharmacy practice, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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28
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A review of the use of direct oral anticoagulant use in orthotopic heart transplantation recipients. Transplant Rev (Orlando) 2018; 32:151-156. [DOI: 10.1016/j.trre.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 04/05/2018] [Accepted: 04/05/2018] [Indexed: 11/20/2022]
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Josyln JA, Khattak FH, Geraci SA. A Case of a Reversible Neurologic Adverse Reaction to Apixaban Confirmed by Re-Challenge. J Clin Med Res 2018; 10:523-526. [PMID: 29707095 PMCID: PMC5916542 DOI: 10.14740/jocmr3394w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 03/30/2018] [Indexed: 12/16/2022] Open
Abstract
Post-marketing reporting of adverse drug events is essential for new medications, as pre-FDA approval studies lack sufficient subject numbers to detect signals for rare events. Prescriptions for the novel oral anticoagulant factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) have equaled or exceeded those for vitamin K antagonists in many clinical settings requiring chronic anticoagulation, and those of injectable heparins for deep vein thrombosis prophylaxis. We report the case of a 60-year-old woman followed for permanent atrial fibrillation who was prescribed apixaban. She rapidly developed worsening neurologic symptoms of imbalance and non-vertiginous dizziness preventing her from walking, headache, diplopia, and confusion/disorientation. Her symptoms began to resolve after stopping the drug, with return to baseline function within 72 h. Unbeknownst to her cardiology care team, the patient chose to re-challenge herself with apixaban at the same dose, producing identical symptoms and again total symptom resolution within 24 h of drug discontinuation. When seen by her physician, her physical examination was unchanged from her pre-treatment baseline. Symptoms did not recur when switched to rivaroxaban therapy.
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Affiliation(s)
| | - Furqan H Khattak
- Quillen College of Medicine, Johnson City, TN, USA.,Division of Cardiology, Quillen College of Medicine, Johnson City, TN, USA.,Department of Internal Medicine, Quillen College of Medicine, Johnson City, TN, USA
| | - Stephen A Geraci
- Quillen College of Medicine, Johnson City, TN, USA.,Division of Cardiology, Quillen College of Medicine, Johnson City, TN, USA.,Department of Internal Medicine, Quillen College of Medicine, Johnson City, TN, USA.,Section of Medical Education, James H. Quillen College of Medicine, Johnson City, TN, USA
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Direct-Acting Oral Anticoagulants as Prophylaxis Against Thromboembolism in the Nephrotic Syndrome. Kidney Int Rep 2018; 3:784-793. [PMID: 29989039 PMCID: PMC6035159 DOI: 10.1016/j.ekir.2018.02.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 02/20/2018] [Accepted: 02/26/2018] [Indexed: 01/10/2023] Open
Abstract
We report 2 cases of apixaban use as prophylaxis against thromboembolism in the nephrotic syndrome (NS), and review the existing literature on direct-acting oral anticoagulant (DOAC) use in this scenario. Our cases appear to be the first reported use of apixaban as prophylaxis against thromboembolism in NS. We report our systematic review of the existing literature on direct-acting oral anticoagulant (DOAC) use in NS, and discuss theoretical issues relevant to their therapeutic use in this clinical scenario. We searched electronic databases such as OVID, EMBASE, PubMed, and CENTRAL, DARE. The search to identify studies and the application of inclusion and exclusion criteria was performed in duplicate independently. We identified 1 pilot randomized study, 3 case reports, and 3 conference proceedings abstracts relating to DOAC use in NS. These reports all pertain to the treatment of clinically evident thrombosis in NS with rivaroxaban, edoxaban, and dabigatran rather than prophylaxis against thrombosis. Although the existing literature on DOAC use in NS is limited, initial preliminary experience appears promising.
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Abstract
Direct oral anticoagulants (DOACs) are increasingly prescribed substances in patients with indication for effective anticoagulation. Patients with chronic kidney disease (CKD) have a high burden of cardiovascular risk and are more likely to develop atrial fibrillation (AF) than patients without CKD. Patients with mild to moderate CKD benefit from DOACs, especially when having intolerance to vitamin K-antagonists (VKA). DOACs may in some cases be considered in patients with rare renal disease and hypercoagulabilic state. DOACs are to a large extent eliminated by renal excretion. Since prospective randomised data in CKD patients are sparse, the decision for anticoagulative therapy is challenging especially in patients with severe renal impairment. The direct factor Xa-inhibitors are approved for use even in patients with an estimated glomerular filtration rate (eGFR) between 15 and 30 ml/min. Careful monitoring of renal function on a regular basis is essential before initiation and after start of DOAC, especially for patients at risk for acute renal failure (elderly, diabetics, patients with preexisting kidney disease). None of the DOACs is approved in CKD patients with end-stage-renal-disease (ESRD) with or without dialysis. DOACs are not recommended for kidney transplant patients under immunosuppression with calcineurin inhibitors. In these patients conventional therapy with VKA is the only option, which has to be monitored closely since it has potential adverse effects.
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Stöllberger C. Drug interactions with new oral anticoagulants in elderly patients. Expert Rev Clin Pharmacol 2017; 10:1191-1202. [DOI: 10.1080/17512433.2017.1370369] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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