2021- Recordd CE Program Packet - Jessica Starr.pdf

Oral anticoagulation (OAC) is the mainstay of therapy for atrial fibrillation (AF) and venous thromboembolism (VTE). For decades, vitamin K antagonists (VKA) have been the standard of care for these patients. With the rapid adoption of direct-acting oral anticoagulants (DOACs), major guidelines now give preference to these agents over VKAs in a variety of patients. Presently, patients with stage 5 chronic kidney disease (CKD-5) or end-stage kidney disease (ESKD), with an indication for OAC, have only been studied in one small randomized trial. All DOACs currently marketed in the US with labelling for AF and VTE are eliminated to some degree renally as unchanged drug. Renal elimination is greatest with dabigatran (80%) and edoxaban (50%) and less with rivaroxaban (33%) and apixaban (27%). Small, single-dose pharmacokinetic studies support the dosing recommendations in the product labelling for apixaban and rivaroxaban. Further, the management of these patients is complicated by a higher risk of bleeding compared to the normal population. Despite this, the use of DOACS in patients with CKD has increased. Specifically, in patients with CKD and nonvalvular AF, the overall use of OAC increased from 56.8% in 2009 to 66.3% in 2018. There has also been decrease in the use of warfarin and an increase use of DOACs. In 2013, DOACs were prescribed to 10.7% of patients with CKD compared 45.1% prescribed warfarin. Data from 2018 shows an increase in DOAC use (38.7%) and decrease in warfarin use (24.5%). Specifically, in the stage 4 or 5 CKD patients on OAC, 2018 shows 33.3% receiving a DOAC and 27.1% receiving warfarin.