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Gronich N. Central Nervous System Medications: Pharmacokinetic and Pharmacodynamic Considerations for Older Adults. Drugs Aging 2024; 41:507-519. [PMID: 38814377 PMCID: PMC11193826 DOI: 10.1007/s40266-024-01117-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 05/31/2024]
Abstract
Most drugs have not been evaluated in the older population. Recognizing physiological alterations associated with changes in drug disposition and with the ultimate effect, especially in central nervous system-acting drugs, is fundamental. While considering pharmacokinetics, it should be noted that the absorption of most drugs from the gastrointestinal tract does not change in advanced age. There are only few data about the effect of age on the transdermal absorption of medications such as fentanyl. Absorption from an intramuscular injection may be similar in older adults as in younger patients. The distribution of lipophilic drugs (such as diazepam) is increased owing to a relative increase in the percentage of body fat, causing drug accumulation and prolonged drug elimination following cessation. Phase I drug biotransformation is variably decreased in aging, impacting elimination, and hepatic drug clearance has been shown to decrease in older individuals by 10-40% for most drugs studied. Lower doses of phenothiazines, butyrophenones, atypical antipsychotics, antidepressants (citalopram, mirtazapine, and tricyclic antidepressants), and benzodiazepines (such as diazepam) achieve the same extent of exposure. For renally cleared drugs with no prior metabolism (such as gabapentin), the glomerular filtration rate appropriately estimates drug clearance. Important pharmacodynamic changes in older adults include an increased sedative effect of benzodiazepines at a given drug exposure, and a higher sensitivity to mu opiate receptor agonists and to opioid adverse effects. Artificial intelligence, physiologically based pharmacokinetic modeling and simulation, and concentration-effect modeling enabling a differentiation between the pharmacokinetic and the pharmacodynamic effects of aging might help to close some of the gaps in knowledge.
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Affiliation(s)
- Naomi Gronich
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, 7 Michal St, 3436212, Haifa, Israel.
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 3200003, Haifa, Israel.
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Wang X, Sin CF, Teo KC, Leung WCY, Wong YK, Liu RKC, Fok JW, Ip BY, Kwan HH, Lee TC, Sheng B, Yip EKK, Yap DYH, Luo H, Lau KK. Impact of renal function variability on long-term prognosis in ischemic stroke patients with atrial fibrillation. Front Neurol 2024; 15:1294022. [PMID: 38711560 PMCID: PMC11071668 DOI: 10.3389/fneur.2024.1294022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 03/25/2024] [Indexed: 05/08/2024] Open
Abstract
Background Although renal dysfunction is associated with adverse clinical outcomes in patients with atrial fibrillation (AF) following stroke, the impact of renal function variability is unclear. Aim This study aimed to assess the association between renal function variability and various adverse clinical outcomes in patients with transient ischemic attack (TIA)/ischemic stroke and atrial fibrillation (AF). Methods We conducted a population-based study and retrospectively identified patients hospitalized with a diagnosis of TIA/ischemic stroke and AF during 2016-2020 using the Clinical Data Analysis and Reporting System of Hong Kong. Serial serum creatinine tested upon the onset of TIA/ischemic stroke and during their subsequent follow-up was collected. Renal function variability was calculated using the coefficient of variation of the estimated glomerular filtration rate (eGFR). Clinical endpoints that occurred during the study period were captured and included ischemic stroke/systemic embolism, intracerebral hemorrhage (ICH), total bleeding, major adverse cardiovascular events (MACE), cardiovascular, non-cardiovascular, and all-cause mortality. Competing risk regression and Cox proportional hazard regression models were used to assess the associations of renal function variability with the outcomes of interest. Results A total of 3,809 patients (mean age 80 ± 10 years, 43% men) who satisfied the inclusion and exclusion criteria were followed up for a mean of 2.5 ± 1.5 years (9,523 patient-years). The mean eGFR was 66 ± 22 mL/min/1.73 m2 at baseline, and the median number of renal function tests per patient during the follow-up period was 20 (interquartile range 11-35). After accounting for potential confounders, a greater eGFR variability was associated with increased risks of recurrent ischemic stroke/systemic embolism [fully adjusted subdistribution hazard ratio 1.11, 95% confidence interval (CI) 1.03-1.20], ICH (1.17, 1.01-1.36), total bleeding (1.13, 1.06-1.21), MACE (1.22, 1.15-1.30), cardiovascular (1.49, 1.32-1.69), non-cardiovascular (1.43, 1.35-1.52), and all-cause mortality (fully adjusted hazard ratio 1.44, 1.39-1.50). Conclusion Visit-to-visit renal function variability is independently associated with adverse clinical outcomes in TIA/ischemic stroke patients with AF. Further large-scale studies are needed to validate our results.
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Affiliation(s)
- Xiao Wang
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chun-fung Sin
- Department of Pathology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Kay-Cheong Teo
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - William C. Y. Leung
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yuen-Kwun Wong
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Roxanna K. C. Liu
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Joshua W. Fok
- Department of Medicine, Yan Chai Hospital, Hong Kong, Hong Kong SAR, China
| | - Bonaventure Y. Ip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hon Hang Kwan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, Hong Kong SAR, China
| | - Tsz Ching Lee
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Bun Sheng
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, Hong Kong SAR, China
| | - Edwin Kin-Keung Yip
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Hong Kong, Hong Kong SAR, China
| | - Desmond Y. H. Yap
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hao Luo
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Computer Science, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Kui-Kai Lau
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
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Lu K, Liao QQ, Zhu KW, Yao Y, Cui XJ, Chen P, Bi Y, Zhong M, Zhang H, Tang JC, Yu Q, Yue JK, He H, Zhu ZF, Cai ZZ, Yang Z, Zhang W, Dong YT, Wei QM, He X. Efficacy and Safety of Different Doses of Rivaroxaban and Risk Factors for Bleeding in Elderly Patients with Venous Thromboembolism: A Real-World, Multicenter, Observational, Cohort Study. Adv Ther 2024; 41:391-412. [PMID: 37987918 DOI: 10.1007/s12325-023-02717-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) consists of deep vein thrombosis (DVT) and pulmonary embolism (PE). Rivaroxaban is a direct oral anticoagulant (DOAC) inhibiting activated coagulation factor X (FXa), and exerts several advantages in the treatment of VTE compared to conventional therapy. However, the efficacy and safety of rivaroxaban in elderly patients with VTE was still poorly understood. METHODS The study was carried out using an observational and non-interventional approach. A total of 576 patients aged ≥ 60 years with newly diagnosed VTE were included in the study. All patients received rivaroxaban with recommended treatment duration of ≥ 3 months for secondary prevention. In addition, 535 elderly patients with various diseases except VTE were included in the study in a retrospective and randomized way. RESULTS The total bleeding rate was 12.2% (70/576). Major bleeding and non-major clinically relevant (NMCR) bleeding occurred in 4 (0.69%) patients and 5 (0.87%) patients, respectively. The rate of recurrent VTE was 5.4%. The mean level of D-dimers was increased by 467.2% in the elderly patients with VTE compared with the elderly patients without VTE. The elderly patients with VTE receiving rivaroxaban at a dose of 10 mg once daily (n = 134) had lower risk for bleeding (3.7% vs 14.7%; P = 0.001) and a similar rate of recurrent VTE (4.5% vs 5.7%; P = 0.596) as compared to the elderly patients with VTE receiving rivaroxaban at higher doses including 15 mg once daily and 20 mg once daily (n = 442). In addition, age, concomitant aspirin, hemoglobin, activated partial thromboplastin time (APTT), and rivaroxaban doses were independent predictive factors for bleeding events. CONCLUSIONS The study suggested that a dose of 10 mg once daily should be the priority in elderly patients with VTE receiving long-term rivaroxaban anticoagulation therapy in view of reduced bleeding risk.
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Affiliation(s)
- Kepeng Lu
- Department of Pharmacy, The First Affiliated Hospital of Henan University of Science and Technology, No. 24 Jinghua Road, Jianxi District, Luoyang, China
| | - Qian-Qian Liao
- Department of Pharmacy, People's Hospital of Guilin, No.12 Civilization Road, Xiangshan District, Guilin, China
| | - Ke-Wei Zhu
- Office of Pharmacovigilance, GuangZhou BaiYunShan Pharmaceutical Holdings CO., LTD. BaiYunShan Pharmaceutical General Factory, No. 88 Yunxiang Road Tonghe Street, Baiyun District, Guangzhou, 510515, Guangdong Province, China.
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, No. 110 Xiangya Road, Changsha, China.
| | - Ying Yao
- Department of Pharmacy, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University, No. 301 Zhengyuan North Street, Jinfeng District, Yinchuan, China
| | - Xiao-Jiao Cui
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32 West Second Section, 1st Ring Road, Qingyang District, Chengdu, China
| | - Peng Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, No. 110 Xiangya Road, Changsha, China
| | - Ying Bi
- Department of Pharmacy, Nanchang Hongdu Hospital of TCM, No. 128 Xiangshan North Road, Donghu District, Nanchang, China
| | - Meng Zhong
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Jiangyang District, Luzhou, China
| | - Hao Zhang
- Department of Pharmacy, People's Hospital of Guilin, No.12 Civilization Road, Xiangshan District, Guilin, China
| | - Jing-Cai Tang
- Administration Office of Medication Clinical Trial, People's Hospital of Guilin, No.12 Civilization Road, Xiangshan District, Guilin, China
| | - Qin Yu
- Department of Pharmacy, People's Hospital of Guilin, No.12 Civilization Road, Xiangshan District, Guilin, China
| | - Jia-Kui Yue
- Department of Pharmacy, The Second Affiliated Hospital of Guilin Medical University, No. 212 Renmin Road, Lingui District, Guilin, China
| | - Hui He
- Department of Pharmacology, Renshou People's Hospital, No. 177, Section 1, Longtan Avenue, Huairen Street, Renshou County, Meishan, China
| | - Ze-Feng Zhu
- Department of Pharmacy, Affiliated Hospital of Guilin Medical University, No. 15 Lequn Road, Guilin, China
| | - Ze-Zheng Cai
- Department of Pharmacology, People's Hospital of Qiandongnan Prefecture, No. 31 Shaoshan South Road, Kaili, Qiandongnan Miao and Dong Autonomous Prefecture, China
| | - Zhe Yang
- Department of Pharmacy, North China Medical Health Group Xingtai General Hospital, No. 202 Bayi Street, Xingtai, China
| | - Wei Zhang
- Department of Pharmacy, Yangquan Coal Industry (Group) General Hospital, No. 218 North Street, Mining Area, Yangquan, China
- Department of Pharmacy, The First Affiliated Hospital of Hainan Medical University, No.31 Longhua Road, Longhua District, Haikou, China
| | - Yang-Tao Dong
- Department of Pharmacy, People's Hospital of Guilin, No.12 Civilization Road, Xiangshan District, Guilin, China
| | - Qiu-Mian Wei
- Department of Pharmacy, People's Hospital of Guilin, No.12 Civilization Road, Xiangshan District, Guilin, China
| | - Xuegai He
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Henan University of Science and Technology, No. 24 Jinghua Road, Jianxi District, Luoyang, 471003, Henan Province, China.
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Villain C, Ebert N, Bothe T, Barghouth M, Pöhlmann A, Fietz AK, Douros A, Mielke N, Schaeffner E. Kidney function estimators for drug dose adjustment of direct oral anticoagulants in older adults with atrial fibrillation. Clin Kidney J 2023; 16:2661-2671. [PMID: 38046038 PMCID: PMC10689126 DOI: 10.1093/ckj/sfad218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Indexed: 12/05/2023] Open
Abstract
Background The Cockcroft-Gault equation (CrClC-G) is recommended for dose adjustment of direct oral anticoagulant drugs (DOACs) to kidney function. We aimed to assess whether defining DOAC dose appropriateness according to various kidney function estimators changed the associations between dose appropriateness and adverse events in older adults with atrial fibrillation (AF). Methods Participants of the Berlin Initiative Study with AF and treated with DOACs were included. We investigated CrClC-G and estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration and European Kidney Function Consortium equations based on creatinine and/or cystatin C. Marginal structural Cox models yielded confounder-adjusted hazard ratios for the risk of mortality, thromboembolism and bleeding associated with dose status. Results A total of 224 patients were included in the analysis (median age 87 years). Using CrClC-G, 154 (69%) had an appropriate dose of DOACs, 52 (23%) were underdosed and 18 (8%) were overdosed. During a 39-month median follow-up period, 109 (14.9/100 person-years) participants died, 25 (3.6/100 person-years) experienced thromboembolism and 60 (9.8/100 person-years) experienced bleeding. Dose status was not associated with mortality and thromboembolism, independent of the equation. Underdose status was associated with a lower risk of bleeding with all the equations compared with the appropriate dose group. In participants with discrepancies in dose status using CrClC-G and eGFR equations, the occurrence of endpoints did not differ between participants having an appropriate dose using CrClC-G or eGFR. Conclusion In older adults with AF, the association of DOAC dose status with adverse events did not differ when using CrClC-G or eGFR. Our results suggest that eGFR equations are not inferior to CrClC-G within this context.
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Affiliation(s)
- Cédric Villain
- Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Public Health, Berlin, Germany
- Normandie Univ UNICAEN, INSERM U1075 COMETE, service de Gériatrie, CHU de Caen, Caen, France
| | - Natalie Ebert
- Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Public Health, Berlin, Germany
| | - Tim Bothe
- Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Public Health, Berlin, Germany
| | - Muhammad Barghouth
- Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Public Health, Berlin, Germany
| | - Anna Pöhlmann
- Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Public Health, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Anne-Katrin Fietz
- Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Public Health, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Antonios Douros
- Departments of Medicine and of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Institute of Clinical Pharmacology and Toxicology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nina Mielke
- Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Public Health, Berlin, Germany
| | - Elke Schaeffner
- Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Public Health, Berlin, Germany
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Hindley B, Lip GYH, McCloskey AP, Penson PE. Pharmacokinetics and pharmacodynamics of direct oral anticoagulants. Expert Opin Drug Metab Toxicol 2023; 19:911-923. [PMID: 37991392 DOI: 10.1080/17425255.2023.2287472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have overtaken vitamin K antagonists to become the most widely used method of anticoagulation for most indications. Their stable and predictable pharmacokinetics combined with relatively simple dosing, and the absence of routine monitoring has made them an attractive proposition for healthcare providers. Despite the benefits of DOACs as a class, important differences exist between individual DOAC drugs in respect of their pharmacokinetic and pharmacodynamic profiles with implications for dosing and reversal in cases of major bleeding. AREAS COVERED This review summarizes the state of knowledge relating to the pharmacokinetics of dabigatran (factor IIa/thrombin inhibitor) and apixaban, edoxaban and rivaroxaban (factor Xa) inhibitors. We focus on pharmacokinetic differences between the drugs which may have clinically significant implications. EXPERT OPINION Patient-centered care necessitates a careful consideration of the pharmacokinetic and pharmacodynamic differences between DOACs, and how these relate to individual patient circumstances. Prescribers should be aware of the potential for pharmacokinetic drug interactions with DOACs which may influence prescribing decisions in patients with multiple comorbidities. In order to give an appropriate dose of DOAC drugs, accurate estimation of renal function using the Cockcroft-Gault formula using actual body weight is necessary. An increasing body of evidence supports the use of DOACs in patients who are obese, and this is becoming more routine in clinical practice.
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Affiliation(s)
- B Hindley
- Pharmacy Department, Aintree University Hospital, Liverpool, UK
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - A P McCloskey
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - P E Penson
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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Bhalodia NJ, White EM, Achanta A, Cheng J, Deri CR, Stahl K, Heiney H, Marchionda O, Iasella CJ, Coons JC. DOAC Dosing Discordance Using Different Estimates of Kidney Function and Outcomes. J Clin Pharmacol 2023; 63:1061-1066. [PMID: 37178305 DOI: 10.1002/jcph.2283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/08/2023] [Accepted: 05/08/2023] [Indexed: 05/15/2023]
Abstract
Direct oral anticoagulants (DOACs) are indicated for the prevention of stroke in nonvalvular atrial fibrillation. Although Food and Drug Administration labeling for DOACs uses estimated creatinine clearance according to the Cockcroft-Gault (C-G) equation, estimated glomerular filtration rate according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is often reported. The objectives of this study were to evaluate DOAC dosing discordance and to determine whether discordance based on various estimates of kidney function is associated with bleeding or thromboembolism. The study was an institutional review board approved retrospective analysis of patients at UPMC Presbyterian Hospital from January 1, 2010, to December 12, 2016. Data were obtained through electronic medical records. Adults who received a medication charge for rivaroxaban or dabigatran, had a diagnosis code for atrial fibrillation, and had a serum creatinine within 3 days of DOAC initiation were included. Doses were considered discordant if the calculated dose based on CKD-EPI did not match the patient's dose during index admission, if dosed correctly using C-G. Association of discordance with dabigatran, rivaroxaban, and clinical outcomes was determined using odds ratios and 95% confidence intervals. Rivaroxaban discordance was present among 49 of the 644 (8%) patients who were dosed correctly with C-G. Dabigatran discordance was present among 17 of the 590 (3%) patients who were dosed correctly. Discordance with rivaroxaban was found to increase the risk of thromboembolism when using CKD-EPI (odds ratio, 2.83; 95% CI, 1.02-7.79, P = .045) versus C-G. Our findings emphasize the need to dose DOACs, specifically rivaroxaban, appropriately in patients with nonvalvular atrial fibrillation.
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Affiliation(s)
- Nauka J Bhalodia
- University of Pittsburgh School of Pharmacy Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital Salk Hall, Pittsburgh, PA, USA
| | - Evan M White
- University of Pittsburgh School of Pharmacy Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital Salk Hall, Pittsburgh, PA, USA
| | - Archita Achanta
- University of Pittsburgh School of Pharmacy Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital Salk Hall, Pittsburgh, PA, USA
| | - Jesse Cheng
- University of Pittsburgh School of Pharmacy Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital Salk Hall, Pittsburgh, PA, USA
| | - Connor R Deri
- University of Pittsburgh School of Pharmacy Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital Salk Hall, Pittsburgh, PA, USA
| | - Kelsey Stahl
- University of Pittsburgh School of Pharmacy Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital Salk Hall, Pittsburgh, PA, USA
| | - Heather Heiney
- University of Pittsburgh School of Pharmacy Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital Salk Hall, Pittsburgh, PA, USA
| | - Olivia Marchionda
- University of Pittsburgh School of Pharmacy Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital Salk Hall, Pittsburgh, PA, USA
| | - Carlo J Iasella
- University of Pittsburgh School of Pharmacy Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital Salk Hall, Pittsburgh, PA, USA
| | - James C Coons
- University of Pittsburgh School of Pharmacy Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital Salk Hall, Pittsburgh, PA, USA
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Challenges and Possible Solutions to Direct-Acting Oral Anticoagulants (DOACs) Dosing in Patients with Extreme Bodyweight and Renal Impairment. Am J Cardiovasc Drugs 2023; 23:9-17. [PMID: 36515822 DOI: 10.1007/s40256-022-00560-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
This article aims to highlight the dosing issues of direct oral anticoagulants (DOACs) in patients with renal impairment and/or obesity in an attempt to develop solutions employing advanced data-driven techniques. DOACs have become widely accepted by clinicians worldwide because of their superior clinical profiles, more predictable pharmacokinetics, and hence more convenient dosing relative to other anticoagulants. However, the optimal dosing of DOACs in extreme bodyweight patients and patients with renal impairment is difficult to achieve using the conventional dosing approach. The standard dosing approach (fixed-dose) is based on limited data from clinical studies. The existing formulae (models) for determining the appropriate doses for these patient groups leads to suboptimal dosing. This problem of mis-dosing is worsened by the lack of standardized laboratory parameters for monitoring the exposure to DOACs in renal failure and extreme bodyweight patients. Model-informed precision dosing (MIPD) encompasses a range of techniques like machine learning and pharmacometrics modelling, which could uncover key variables and relationships as well as shed more light on the pharmacokinetics and pharmacodynamics of DOACs in patients with extreme bodyweight or renal impairment. Ultimately, this individualized approach-if implemented in clinical practice-could optimise dosing for the DOACs for better safety and efficacy.
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Ono R, Nishimura K, Takahashi H, Hori Y, Fukushima K, Kobayashi Y. Impact of Renal Function on Anti-factor Xa Activity Concentrations with Edoxaban Use in Patients with Non-valvular Atrial Fibrillation. Drugs R D 2022; 22:281-288. [DOI: 10.1007/s40268-022-00403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/24/2022] Open
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Rohla M, Pecen L, Cemin R, Patti G, Siller-Matula JM, Schnabel RB, Huber K, Kirchhof P, De Caterina R. Reclassification, Thromboembolic, and Major Bleeding Outcomes Using Different Estimates of Renal Function in Anticoagulated Patients With Atrial Fibrillation: Insights From the PREFER-in-AF and PREFER-in-AF Prolongation Registries. Circ Cardiovasc Qual Outcomes 2021; 14:e006852. [PMID: 34078099 DOI: 10.1161/circoutcomes.120.006852] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The Cockcroft-Gault formula is recommended to determine a renal indication for dose reduction of dabigatran, edoxaban, and rivaroxaban. Nephrology guidelines now recommend the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulae as more accurate estimates of glomerular filtration rate. METHODS We analyzed anticoagulated patients with atrial fibrillation who were enrolled in the Prevention of Thromboembolic Events - European Registry in Atrial Fibrillation (PREFER in AF). The proportion of patients with dissimilar renal dosing indications was assessed when applying Cockcroft-Gault, MDRD, or CKD-EPI. Thromboembolic and major bleeding events at 1 year were compared in patients in whom Cockcroft-Gault and CKD-EPI provided concordant or discordant results around a threshold of 50 mL/minute. RESULTS Out of 1288 patients with atrial fibrillation with chronic kidney disease in whom Cockcroft-Gault suggested a dose reduction of dabigatran, edoxaban, or rivaroxaban (creatinine clearance ≤50 mL/minutes), 19% and 16% were reclassified to the respective higher doses, and 24% and 23% to the respective lower doses by applying the MDRD and CKD-EPI formulae, respectively. In patients potentially receiving a different dose of dabigatran, edoxaban, or rivaroxaban when using CKD-EPI, we observed an excess of thromboembolic events (4.1% versus 0.8%; odds ratio, 5.5 [95% CI, 1.5-20.8]; P=0.01). Major bleeding rates were nonsignificantly different in the discordance versus concordance group (5.7% versus 2.7%; odds ratio, 2.2 [95% CI, 0.9-5.6]; P=0.09). CONCLUSIONS The MDRD and CKD-EPI formulae suggest a different dosing in up to a quarter of anticoagulated patients with atrial fibrillation. This seems to impact hard outcomes.
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Affiliation(s)
- Miklos Rohla
- 3 Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria (M.R., K.H.).,Institute for Cardiometabolic Diseases, Karl Landsteiner Society, St. Pölten, Austria (M.R.)
| | - Ladislav Pecen
- Medical Faculty Pilsen, Charles University, Czech Republic (L.P.)
| | - Roberto Cemin
- Department of Cardiology, San Maurizio Regional Hospital of Bolzano, Italy (R.C.)
| | - Giuseppe Patti
- University of Eastern Piedmont, Maggiore della Carità Hospital of Novara, Italy (G.P.)
| | - Jolanta M Siller-Matula
- Department of Cardiology, Medical University of Vienna, Austria (J.M.S.-M.).,Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Poland (J.M.S.-M.)
| | - Renate B Schnabel
- University Heart Center Hamburg, Clinic for General and Interventional Cardiology, Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (R.B.S.)
| | - Kurt Huber
- 3 Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria (M.R., K.H.).,Sigmund Freud University, Medical School, Vienna, Austria (K.H.)
| | - Paulus Kirchhof
- University of Birmingham Institute of Cardiovascular Sciences, University of Birmingham, UHB and SWBH NHS Trusts, United Kingdom (P.K.)
| | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Cardiology Division, Pisa University Hospital, Italy (R.D.C.)
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10
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Dobesh PP, Kernan MM, Lueshen JJ. Direct Oral Anticoagulants in the Treatment of Venous Thromboembolism: Use in Patients with Advanced Renal Impairment, Obesity, or Other Weight-Related Special Populations. Semin Respir Crit Care Med 2021; 42:233-249. [PMID: 33601428 DOI: 10.1055/s-0041-1723952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
There are currently more than 7 million patients taking a direct oral anticoagulant (DOAC), with more new prescriptions per year than warfarin. Despite impressive efficacy and safety data for the treatment of venous thromboembolism, patients with obesity or advanced renal impairment represented a small portion of the patients enrolled in the phase 3 clinical trials. Therefore, to evaluate the potential use of DOACs in these special populations, clinicians need to have an understanding of the pharmacokinetics and pharmacodynamics of these agents in these settings. Since data from randomized controlled trials are limited, data from observational trials are helpful in gaining comfort with the use of DOACs in these special populations. Selecting the appropriate dose for each agent is imperative in achieving optimal patient outcomes. We provide an extensive review of the pharmacokinetics, pharmacodynamics, phase 3 clinical trials, and observational studies on the use of DOACs in patients with advanced renal impairment, obesity, or other weight-related special populations to provide clinicians with a comprehensive understanding of the data for optimal drug and dose selection.
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Affiliation(s)
- Paul P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, Nebraska
| | - Molly M Kernan
- College of Pharmacy, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, Nebraska
| | - Jenni J Lueshen
- College of Pharmacy, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, Nebraska
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11
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Wada R, Shinohara M, Nakanishi R, Kinosihita T, Yuzawa H, Ikeda T. Relationship between the degree of renal dysfunction and the safety and efficacy outcomes in patients with atrial fibrillation receiving direct oral anticoagulants. J Arrhythm 2021; 37:88-96. [PMID: 33664890 PMCID: PMC7896459 DOI: 10.1002/joa3.12493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/20/2020] [Accepted: 12/03/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The clinical evaluation of a direct oral anticoagulant (DOAC) treatment for atrial fibrillation (AF) patients with renal dysfunction has not been sufficiently studied. This study aimed to evaluate the safety and efficacy of DOACs for patients with a severely impaired renal function. METHODS This was a retrospective and observational study in a single center. We enrolled 894 consecutive AF patients who were prescribed DOACs, and divided them into three groups based on their creatinine clearance (CrCl) value: CrCl ≥ 50 mL/min group (n = 634), CrCl 30-49 mL/min group (n = 207), and CrCl 15-29 mL/min group (n = 53). We evaluated the occurrence of major bleeding (MB) as the safety outcome and thromboembolic events (TEs) as the efficacy outcome during the follow-up. RESULTS The incidence of MB in the CrCl 15-29 mL/min group was significantly higher than in the other groups (CrCl ≥ 50 mL/min group, 0.8/100 person-years; CrCl 30-49 mL/min group, 1.2/100 person-years; CrCl 15-29 mL/min group, 9.0/100 person-years, log rank test, P < .001). On the other hand, there was no significant difference in the incidence of TEs among the three groups. A multivariate analysis using a Cox proportional hazard model adjusted for the age revealed that the CrCl 15-29 mL/min group was significantly associated with increased MB compared to the CrCl ≥ 50 mL/min group (hazard ratio: 9.76, 95% confidence interval: 2.69-35.5, P < .001). Similar results were observed when adjusting for other multiple clinical factors. CONCLUSION This study demonstrated that the degree of renal dysfunction was a significant prognostic factor for MB in AF patients receiving DOACs.
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Affiliation(s)
- Ryo Wada
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Masaya Shinohara
- Division of Cardiovascular MedicineDepartment of Internal MedicineToho University Faculty of MedicineTokyoJapan
| | - Rine Nakanishi
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Toshio Kinosihita
- Division of Cardiovascular MedicineDepartment of Internal MedicineToho University Faculty of MedicineTokyoJapan
| | - Hitomi Yuzawa
- Division of Cardiovascular MedicineDepartment of Internal MedicineToho University Faculty of MedicineTokyoJapan
| | - Takanori Ikeda
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
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12
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Seiberth S, Terstegen T, Strobach D, Czock D. Accuracy of freely available online GFR calculators using the CKD-EPI equation. Eur J Clin Pharmacol 2020; 76:1465-1470. [PMID: 32562002 PMCID: PMC7481157 DOI: 10.1007/s00228-020-02932-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/09/2020] [Indexed: 11/30/2022]
Abstract
Purpose Estimated glomerular filtration rate (eGFR) as calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is used for detection of chronic kidney disease and drug dose adjustment. The purpose of the present study was to investigate the accuracy of freely available eGFR online calculators. Methods All identified CKD-EPI online calculators were run with five reference cases differing in age, sex, serum creatinine, and ethnicity. Conversion from eGFRindexed (unit ml/min per 1.73 m2) to eGFRnon-indexed (unit ml/min) and creatinine unit from milligramme/decilitre to micromole/litre was checked, if available. Results Only 36 of 47 calculators (76.6%) produced accurate eGFR results for all reference cases. Eight of 47 (17.0%) calculators were considered as faulty because of errors relating to ethnicity (4 calculators), to conversion of the eGFR unit (2 calculators), to erroneous eGFR values without obvious explanation (2 calculators), to conversion of the creatinine unit (1 calculator), and to an error in the eGFR unit displayed (1 calculator). Overall, 28 errors were found (range 59 to 147% of the correct eGFR value), the majority concerning calculation of eGFRindexed and the conversion to eGFRnon-indexed. Only 7 of 47 (14.9%) calculators offered conversion of the eGFR unit. Conclusions Erroneous calculations that might lead to inappropriate clinical decision-making were found in 8 of 47 calculators. Thus, online calculators should be evaluated more thoroughly after implementation. Conversion of eGFR units that might be needed for drug dose adjustments should be implemented more often. Electronic supplementary material The online version of this article (10.1007/s00228-020-02932-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Seiberth
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - Theresa Terstegen
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Dorothea Strobach
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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13
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Nabiee M, Dashti-Khavidaki S, Khajeh B. Dose discordance of direct acting oral anticoagulants using different equations for estimating GFR: a literature review. Expert Rev Clin Pharmacol 2020; 13:857-863. [DOI: 10.1080/17512433.2020.1798759] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Morteza Nabiee
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Simin Dashti-Khavidaki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Behrouz Khajeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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14
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Should We Continue Assessing Glomerular Filtration Rate with the Cockroft-Gault Formula in NOAC-Treated Patients? The Magnitude of the Problem. J Clin Med 2020; 9:jcm9061893. [PMID: 32560421 PMCID: PMC7355413 DOI: 10.3390/jcm9061893] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/30/2020] [Accepted: 06/12/2020] [Indexed: 12/03/2022] Open
Abstract
Despite the proven superiority of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) over the Cockcroft–Gault (CG) formula, current guidelines recommend the latter to assess renal function in patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). To assess the relationship between the CG and the recommended CKD-EPI formulas, in a cohort of atrial fibrillation (AF) patients treated with NOACs, and the misclassifications introduced by the CG formula for renal function levels, we estimated renal function with three equations: CG, CKD-EPI with body surface adjustment (1.73 mL/m2, CKD-EPI) and without such adjustment (CKD-EPI_noBSA), in all consecutive AF patients discharged from NOACs from the Cardiology Division of a main city hospital between February 1st and May 31st 2018. We compared the different estimates of glomerular filtration rate and potential renal function class misclassifications. We reclassified 37/115 patients (32.1%) when switching from the CG to the CKD-EPI; and 24/115 (20.8%) switching from the CG to the CKD-EPI_noBSA formulas. Class reallocation was distributed across all levels of renal function, but mostly affected the “hyper-normal” function. In estimating consequences of such reallocation, a change in NOAC dosages would have occurred in 10/115 patients (8.7%) when switching from the CG to the CKD-EPI formula and in 10/115 patients when switching from the CG to the CKD-EPI_noBSA formula. Although the CG method has been traditionally used to calculate renal function in all NOAC studies, a renal dysfunction class reallocation occurs in a substantial fraction of hospital-admitted AF patients with the use of better estimates of renal function.
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15
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Santos J, António N, Rocha M, Fortuna A. Impact of direct oral anticoagulant off-label doses on clinical outcomes of atrial fibrillation patients: A systematic review. Br J Clin Pharmacol 2020; 86:533-547. [PMID: 31631392 DOI: 10.1111/bcp.14127] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/14/2019] [Accepted: 09/07/2019] [Indexed: 12/23/2022] Open
Abstract
AIMS Worldwide observational studies are evidencing discordance between guidelines and real-world practice regarding direct oral anticoagulant drug (DOAC) doses. This systematic review summarizes and evaluate DOACs use in real-world practice. METHODS This review was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines searching PubMed (MEDLINE) and Medscape databases. RESULTS Data from 75 studies showed that most of the patients treated with DOACs for stroke prevention in atrial fibrillation received doses in accordance to the guidelines. However, a significant number of patients received off-label doses (25-50% in most of the studies evaluated). DOAC overdosing was associated with increased all-cause mortality and worse bleeding events while underdosing was associated with increased cardiovascular hospitalization and, particularly for apixaban, with a nearly 5-fold increased risk of stroke. CONCLUSION Patients prescribed with off-label DOAC doses did not receive the full benefit of anticoagulation and presented an increased risk of stroke, bleeding and/or adverse effects.
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Affiliation(s)
- Joana Santos
- Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Natália António
- Laboratory of Pharmacology, Faculty of Medicine, University of Coimbra, Portugal.,Cardiology Department, Coimbra Hospital and Universitary Centre, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal
| | - Marília Rocha
- Pharmaceutical Service, Coimbra Hospital and Universitary Centre, Portugal
| | - Ana Fortuna
- Laboratory of Pharmacology and Pharmaceutical Care, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal.,CIBIT/ICNAS - Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Coimbra, Portugal
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16
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Briasoulis A, Gao Y, Inampudi C, Alvarez P, Asleh R, Chrischilles E, Leira EC, Vaughan-Sarrazin M. Characteristics and outcomes in patients with atrial fibrillation receiving direct oral anticoagulants in off-label doses. BMC Cardiovasc Disord 2020; 20:42. [PMID: 32013886 PMCID: PMC6998084 DOI: 10.1186/s12872-020-01340-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 01/13/2020] [Indexed: 12/19/2022] Open
Abstract
Background We evaluated adherence to dosing criteria for patients with atrial fibrillation (AF) taking dabigatran or rivaroxaban and the impact of off-label dosing on thromboembolic and bleeding risk. Methods We used data for a retrospective cohort from a large U.S. health plan for Medicare beneficiaries age > =65 years with AF who initiated dabigatran or rivaroxaban during 2010–2016. Stroke and major bleeding were quantified in patients who were eligible for low dose but received standard dose, and in patients who were eligible for standard dose but received low dose. Results We identified 8035 and 19,712 patients who initiated dabigatran or rivaroxaban, respectively. Overall, 1401 (17.4%) and 7820 (39.7%) patients who received dabigatran and rivaroxaban met criteria for low dose, respectively. Of those, 959 (68.5%) and 3904 (49.9%) received standard dose. In contrast, 1013 (15.3%) and 2551 (21.5%) of patients eligible for standard dose dabigatran and rivaroxaban received low dose. Mean follow-up for patients eligible for low and standard dose dabigatran and rivaroxaban were 13.9, 15.1, 10.1, and 12.3 months, respectively. In unadjusted analyses, patients eligible for low or standard dose dabigatran and rivaroxaban but receiving off-label dose, had no differences in the rates of ischemic stroke. Among patients who met criteria for standard dose direct oral anticoagulants (DOAC), use of low dose was associated with significantly higher risk of any major bleeding (Dabigatran: HR = 1.44; 95% CI 1.14–1.8, P = 0.002, Rivaroxaban HR 1.34, 95% CI 1.11–1.6, P = 0.002) and gastrointestinal bleeding (Dabigatran: HR = 1.48; 95% CI 1.08–2, P = 0.016). In patients who met criteria for low dose DOACs, there was lower risk of major bleeding (Dabigatran: HR = 0.59; 95% CI 0.43–0.8, P < 0.001), gastrointestinal (Rivaroxaban: HR 0.79; 95% CI 0.64–0.98, P = 0.03) and intracranial bleeding (Dabigatran: HR = 0.33; 95% CI 0.12–0.9, P = 0.001) with standard dosing. After propensity matching, use of off-label doses was not associated with stroke, major, gastrointestinal or intracranial bleeding for either dabigatran or rivaroxaban. Conclusions While a significant number of patients receive higher or lower dose of dabigatran and rivaroxaban than recommended, we found no evidence of significant impact on thromboembolic or hemorrhagic outcomes.
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Affiliation(s)
- Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa College of Medicine, Iowa City, IA, USA. .,Division of Cardiovascular Medicine, 200 Hawkins Dr, Iowa City, IA, 52242, USA.
| | - Yubo Gao
- Division of General Medicine, University of Iowa College of Medicine, Iowa City, IA, USA
| | - Chakradhari Inampudi
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa College of Medicine, Iowa City, IA, USA
| | - Paulino Alvarez
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa College of Medicine, Iowa City, IA, USA
| | - Rabea Asleh
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa College of Medicine, Iowa City, IA, USA
| | - Elizabeth Chrischilles
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Enrique C Leira
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA.,Departments of Neurology and Neurosurgery, University of Iowa College of Medicine, Iowa City, USA
| | - Mary Vaughan-Sarrazin
- Division of General Medicine, University of Iowa College of Medicine, Iowa City, IA, USA. .,Comprehensive Access and Delivery Research and Evaluation Center, Iowa City VA Medical Center, IA, 200 Hawkins Dr, Iowa City, IA, 52242, USA.
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17
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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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18
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Liquid chromatographic methods for the determination of direct oral anticoagulant drugs in biological samples: A critical review. Anal Chim Acta 2019; 1076:18-31. [DOI: 10.1016/j.aca.2019.03.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 12/20/2022]
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19
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Petrov VI, Shatalova OV, Gerasimenko AS, Gorbatenko VS. Safety of Using Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Chronic Kidney Disease. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2019. [DOI: 10.20996/1819-6446-2019-15-4-530-537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The purpose of this review is to examine the possibilities and prospects for the use of direct oral anticoagulants for the prevention of thromboembolic complications in patients with atrial fibrillation and chronic kidney disease. Chronic kidney disease is an independent risk factor for cardiovascular complications. Atrial fibrillation is associated with a higher risk of developing chronic kidney disease and more rapid progression of existing renal pathology. The presence of chronic kidney disease in atrial fibrillation on the one hand leads to an increased risk of thromboembolism, and on the other to an increased risk of bleeding when using anticoagulants. The standard for the prevention of thromboembolic complications in atrial fibrillation, including those with concomitant renal pathology, was considered warfarin for many years. However, modern studies have shown that the use of warfarin may enhance vascular calcification in patients with chronic kidney disease, which in turn may lead to an increased risk of ischemic strokes.Analyzing clinical recommendations, randomized studies, meta-analyzes and a systematic review on the use of anticoagulants in patients with atrial fibrillation and renal pathology, revealed the advantage of using direct oral anticoagulants over warfarin at stage 1-3 of chronic kidney disease. Data on the use of direct oral anticoagulants with a more pronounced renal dysfunction and in patients on dialysis is limited due to the lack of a sufficient number of large randomized studies. Due to the presence of renal clearance in all oral anticoagulants, their pharmacokinetics changes to some extent with a decrease in the glomerular filtration rate, which requires dose adjustment of drugs depending on creatinine clearance. Therefore, the use of anticoagulants for the prevention of thromboembolic complications during atrial fibrillation requires special attention in patients with chronic kidney disease.
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20
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Parker K, Thachil J. The use of direct oral anticoagulants in chronic kidney disease. Br J Haematol 2018; 183:170-184. [PMID: 30183070 DOI: 10.1111/bjh.15564] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Increasing use of direct oral anticoagulants (DOACs) has made management of non-valvular atrial fibrillation and venous thromboembolism easier in most patients. But the presence of co-existing renal impairment could render the use of DOACs problematic because all of these drugs have varying degrees of renal excretion. In this paper we address misconceptions about the safety and efficacy of DOACs in moderate-severe renal impairment by presenting a summary of the literature from phase III trials and real-world studies. It also addresses the important consideration of correct estimate of renal function for DOAC dosing. It is hoped that the review will serve as a valuable resource for clinicians involved in anticoagulation decision-making in patients with renal impairment to guide the choice of most suitable agent. Accurate dosing is of particular relevance as registry data suggests it is done inconsistently and may be resulting in avoidable thromboembolic and bleeding events.
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Affiliation(s)
- Kathrine Parker
- Department of Pharmacy, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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21
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Heine GH, Brandenburg V, Schirmer SH. Oral Anticoagulation in Chronic Kidney Disease and Atrial Fibrillation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:287-294. [PMID: 29789105 DOI: 10.3238/arztebl.2018.0287] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 08/07/2017] [Accepted: 02/15/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cardiological societies recommend, in their guidelines, that patients with atrial fibrillation and an intermediate (or higher) risk of stroke and systemic embolization should be treated with oral anticoagulant drugs. For patients who do not have mitral valve stenosis or a mechanical valve prosthesis, non-vitamin-K dependent oral anticoagulants (NOAC) are preferred over vitamin K antagonists (VKA) for this purpose. It is unclear, however, whether patients with chronic kidney disease and atrial fibrillation benefit from oral anticoagulation to the same extent as those with normal kidney function. It is also unclear which of the two types of anti - coagulant drug is preferable for patients with chronic kidney disease; NOAC are, in part, renally eliminated. METHODS This review is based on pertinent publications retrieved by a selective literature search, and on international guidelines. RESULTS Current evidence suggests that patients with atrial fibrillation who have chronic kidney disease with a glomerular filtration rate (GFR) above 15 mL/ min/1.73 m² should be treated with an oral anticoagulant drug if they have an at least intermediate risk of embolization, as assessed with the CHA2DS2-VASc score. For patients with advanced chronic kidney disease (GFR from 15 to 29 mL/ min/1.73 m²), however, this recommendation is based only on registry studies. For dialysis patients with atrial fibrillation, decisions whether to give oral anticoagulant drugs should be taken on an individual basis, in view of the elevated risk of hemorrhage and the unclear efficacy of such drugs in these patients. The subgroup analyses of the NOAC approval studies show that, for patients with atrial fibrillation and chronic kidney disease with a creatinine clearance of >25-30 mL/min, NOAC should be given in preference to VKA, as long as the patient does not have mitral valve stenosis or a mechanical valve prosthesis. For those whose creatinine clearance is less than 25 mL/min, the relative merits of NOAC versus VKA are still debated. CONCLUSION The cardiological societies' recommendation that patients with atrial fibrillation should be given oral anticoagulant drugs applies to the majority of such patients who also have chronic kidney disease.
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Affiliation(s)
- Gunnar H Heine
- Saarland University Medical Center, Saarland University Faculty of Medicine, Internal Medicine IV - Nephrology and Hypertension, Homburg; Department of Cardiology, University Hospital RWTH Aachen; Saarland University Medical Center, Saarland University Faculty of Medicine, Internal Medicine III - Cardiology, Angiology, Intensive Care Medicine, Homburg
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22
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Moore KL, Patel K, Boscardin WJ, Steinman MA, Ritchie C, Schwartz JB. Medication burden attributable to chronic co-morbid conditions in the very old and vulnerable. PLoS One 2018; 13:e0196109. [PMID: 29684077 PMCID: PMC5912775 DOI: 10.1371/journal.pone.0196109] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 04/07/2018] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Polypharmacy is common in older patients but relationships between polypharmacy and common co-morbid conditions have not been elucidated. Our goal was to determine relationships between daily oral medication use and common co-morbid disease dyads and triads using comprehensive medication and diagnostic data from a national sample of nursing homes (NH). DESIGN Retrospective, cross-sectional study. SETTING Nationally representative sample of U.S. Nursing Homes. PARTICIPANTS Nationally representative sample of long-term stay residents (n = 11734, 75% women) aged 65 years or older. MEASUREMENTS Diagnosis and medication data were analyzed. Proportion of daily oral medication intake attributed to treatment of common two-(dyads) and three-disease (triad) combinations and "health maintenance" agents (vitamins, dietary supplements, stool softeners without related diagnoses) was determined. RESULTS Older NH residents received slightly >8 oral medications/day with the number related to number of medical diagnoses (p < .0001). One third of chronic oral medication intake/day (excluding health maintenance agents) could be attributed to dyad combinations and about half to triad combinations despite an average of 5 other diagnoses. Triads were comprised of hypertension +/- arthritis +/- vascular disease, +/-depression, +/- osteoporosis +/- gastroesophageal reflux disease and +/- diabetes. Health maintenance agents accounted for 15-17% of daily oral medication intake (1.4 medications) such that almost two-thirds of daily oral medications were attributable to disease triads plus health maintenance. Fewer medications were prescribed for NH residents over age 85 (decreased ACE inhibitor and HMG CoA reductase inhibitor USE (p < .001)) while use of Alzheimer medications was higher (p < .01). CONCLUSIONS A large fraction of daily oral medications were attributed to management of common co-morbid disease dyads and triads. Efforts to reduce polypharmacy and unwanted medication interactions could focus on regimens for common co-morbid dyads and triads in varying populations.
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Affiliation(s)
- Kelly L. Moore
- Center for Research on Aging of the Jewish Home, San Francisco, CA, United States of America
| | - Kanan Patel
- Center for Research on Aging of the Jewish Home, San Francisco, CA, United States of America
- Department of Medicine, University of California, San Francisco, CA, United States of America
| | - W. John Boscardin
- Department of Medicine, University of California, San Francisco, CA, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, United States of America
| | - Michael A. Steinman
- Department of Medicine, University of California, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Christine Ritchie
- Center for Research on Aging of the Jewish Home, San Francisco, CA, United States of America
- Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Janice B. Schwartz
- Center for Research on Aging of the Jewish Home, San Francisco, CA, United States of America
- Department of Medicine, University of California, San Francisco, CA, United States of America
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, CA, United States of America
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Schwartz JB. Authors Have Incorrectly Calculated Need for Renal Dose Adjustments for NOACs. J Am Coll Cardiol 2017; 70:2731-2732. [PMID: 29169485 DOI: 10.1016/j.jacc.2017.08.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/21/2017] [Indexed: 11/26/2022]
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Alaini A, Malhotra D, Rondon-Berrios H, Argyropoulos CP, Khitan ZJ, Raj DSC, Rohrscheib M, Shapiro JI, Tzamaloukas AH. Establishing the presence or absence of chronic kidney disease: Uses and limitations of formulas estimating the glomerular filtration rate. World J Methodol 2017; 7:73-92. [PMID: 29026688 PMCID: PMC5618145 DOI: 10.5662/wjm.v7.i3.73] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/17/2017] [Accepted: 05/30/2017] [Indexed: 02/06/2023] Open
Abstract
The development of formulas estimating glomerular filtration rate (eGFR) from serum creatinine and cystatin C and accounting for certain variables affecting the production rate of these biomarkers, including ethnicity, gender and age, has led to the current scheme of diagnosing and staging chronic kidney disease (CKD), which is based on eGFR values and albuminuria. This scheme has been applied extensively in various populations and has led to the current estimates of prevalence of CKD. In addition, this scheme is applied in clinical studies evaluating the risks of CKD and the efficacy of various interventions directed towards improving its course. Disagreements between creatinine-based and cystatin-based eGFR values and between eGFR values and measured GFR have been reported in various cohorts. These disagreements are the consequence of variations in the rate of production and in factors, other than GFR, affecting the rate of removal of creatinine and cystatin C. The disagreements create limitations for all eGFR formulas developed so far. The main limitations are low sensitivity in detecting early CKD in several subjects, e.g., those with hyperfiltration, and poor prediction of the course of CKD. Research efforts in CKD are currently directed towards identification of biomarkers that are better indices of GFR than the current biomarkers and, particularly, biomarkers of early renal tissue injury.
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Affiliation(s)
- Ahmed Alaini
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Deepak Malhotra
- Division of Nephrology, Department of Medicine, University of Toledo School of Medicine, Toledo, OH 43614-5809, United States
| | - Helbert Rondon-Berrios
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, United States
| | - Christos P Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Zeid J Khitan
- Division of Nephrology, Department of Medicine, Joan C. Edwards School of Medicine, Huntington, WV 25701, United States
| | - Dominic S C Raj
- Division of Nephrology, Department of Medicine, George Washington University, Washington, DC 20037, United States
| | - Mark Rohrscheib
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Joseph I Shapiro
- Marshall University Joan C. Edwards School of Medicine, Huntington, WV 25701, United States
| | - Antonios H Tzamaloukas
- Nephrology Section, Medicine Service, Raymond G. Murphy VA Medical Center, Albuquerque, NM 87108, United States
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
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25
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Renal Function Considerations for Stroke Prevention in Atrial Fibrillation. Am J Med 2017; 130:1015-1023. [PMID: 28502818 DOI: 10.1016/j.amjmed.2017.04.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 04/14/2017] [Accepted: 04/18/2017] [Indexed: 01/13/2023]
Abstract
Renal impairment increases risk of stroke and systemic embolic events and bleeding in patients with atrial fibrillation. Direct oral anticoagulants (DOACs) have varied dependence on renal elimination, magnifying the importance of appropriate patient selection, dosing, and periodic kidney function monitoring. In randomized controlled trials of nonvalvular atrial fibrillation, DOACs were at least as effective and associated with less bleeding compared with warfarin. Each direct oral anticoagulant was associated with reduced risk of stroke and systemic embolic events and major bleeding compared with warfarin in nonvalvular atrial fibrillation patients with mild or moderate renal impairment. Renal function decrease appears less impacted by DOACs, which are associated with a better risk-benefit profile than warfarin in patients with decreasing renal function over time. Limited data address the risk-benefit profile of DOACs in patients with severe impairment or on dialysis.
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26
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Incomplete Resolution of Deep Vein Thromboses during Rivaroxaban Therapy. Case Rep Cardiol 2017; 2017:3628127. [PMID: 28828188 PMCID: PMC5554577 DOI: 10.1155/2017/3628127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 06/15/2017] [Indexed: 11/24/2022] Open
Abstract
We present the case of a patient with a deep vein thrombosis (DVT) who failed rivaroxaban therapy. Our patient initially presented with left lower extremity edema, erythema, and pain. He was subsequently started on rivaroxaban therapy for a combined treatment period of 12 months, during and after which he persisted to have evidence of a DVT. The patient's prescribed drug regimen was changed from rivaroxaban to warfarin, which demonstrated a rapid resolution of the DVTs as determined by ultrasound assessment of our patient's lower extremity veins. Rivaroxaban, a factor Xa inhibitor, is a well-known oral anticoagulant that is used for a variety of indications and has become a mainstay in the treatment of deep vein thrombosis. With the introduction and emergence of this medication in the clinic, postmarketing reports of efficacy or lack thereof are important to review. In conclusion, we anticipate that it is likely that there are other patients with DVTs who may not respond to rivaroxaban and for whom alternative anticoagulation therapies should be explored.
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27
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Di Lullo L, Ronco C, Cozzolino M, Russo D, Russo L, Di Iorio B, De Pascalis A, Barbera V, Galliani M, Vitaliano E, Campana C, Santoboni F, Bellasi A. Nonvitamin K-dependent oral anticoagulants (NOACs) in chronic kidney disease patients with atrial fibrillation. Thromb Res 2017; 155:38-47. [PMID: 28482261 DOI: 10.1016/j.thromres.2017.04.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/24/2017] [Accepted: 04/28/2017] [Indexed: 12/17/2022]
Abstract
Atrial fibrillation (AF) represents the most common arrhythmia in patients with chronic kidney disease (CKD). As in the general population, in CKD patients AF is associated with an increased risk of thromboembolism and stroke. However, CKD patients, especially those on renal replacement therapy (RRT), also exhibit an increased risk of bleeding, especially from the gastrointestinal tract. Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF presenting increased risk of stroke. Limited evidence on efficacy, the increased risk of bleeding as well as some concern regarding the use of warfarin in CKD, has often resulted in the underuse of anticoagulation CKD patients. A large body of evidence suggests that non-vitamin K-dependent oral anticoagulant agents (NOACs) significantly reduce the risk of stroke, intracranial hemorrhage, and mortality, with lower to similar major bleeding rates compared with vitamin K antagonist such as warfarin in normal renal function subjects. Hence, they are currently recommended for patients with atrial fibrillation at risk for stroke. However, NOACs metabolism is largely dependent on the kidneys for elimination and little is known in patients with creatinine clearance <25ml/min who were excluded from all pivotal phase 3 NOACs trials. This review focuses on the current pharmacokinetic, observational, and prospective data on NOACs in patients with moderate to advanced chronic kidney disease (creatinine clearance 15-49ml/min) and those on dialysis.
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Affiliation(s)
- L Di Lullo
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy.
| | - C Ronco
- International Renal Research Institute, S. Bortolo Hospital, Vicenza, Italy
| | - M Cozzolino
- Department of Health Sciences, Renal Division, S. Paolo Hospital, Milano, Italy
| | - D Russo
- Division of Nephrology, University Federico II, Napoli, Italy
| | - L Russo
- Division of Nephrology, University Federico II, Napoli, Italy
| | - B Di Iorio
- Department of Nephrology and Dialysis, Landolfi Hospital, Solofra, Italy
| | - A De Pascalis
- Department of Nephrology and Dialysis, V. Fazzi Hospital, Lecce, Italy
| | - V Barbera
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy
| | - M Galliani
- Department of Nephrology and Dialysis, S. Pertini Hospital, Roma, Italy
| | - E Vitaliano
- Department of Nephrology and Dialysis, S. Pertini Hospital, Roma, Italy
| | - C Campana
- Cardiology Unit, S. Anna Hospital, ASST - Lariana, Como, Italy
| | - F Santoboni
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy
| | - A Bellasi
- Nephrology Unit, S. Anna Hospital, ASST - Lariana, Como, Italy
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