From the Guidelines
Eliquis (apixaban) is not indicated as a first-line treatment for patients with nephrotic syndrome due to limited pharmacokinetic studies and potential interactions with hypoalbuminemia. The primary concern in managing nephrotic syndrome is treating the underlying cause and managing symptoms, rather than relying on anticoagulation therapy. According to the KDIGO 2021 clinical practice guideline for the management of glomerular diseases 1, anticoagulant dosing considerations in patients with nephrotic syndrome are complex and require careful evaluation.
The guideline recommends prophylactic anticoagulation during transient high-risk events, such as low-dose anticoagulation with molecular-weight heparin or unfractionated heparin, and full warfarin anticoagulation for thromboembolic events 1. However, the use of factor Xa inhibitors, including apixaban, is not systematically studied in patients with nephrotic syndrome, and their pharmacokinetic properties require additional study for both safety and efficacy before they can be generally recommended 1.
Key considerations in nephrotic syndrome include:
- Altered clotting factors and protein levels, which can affect anticoagulant efficacy and safety
- Hypoalbuminemia, which can substantially affect the half-lives of heavily albumin-bound drugs like apixaban
- Increased risk of both thrombosis and bleeding, making anticoagulation decisions complex
- Need for careful monitoring of international normalized ratio (INR) and potential interactions with other medications
In specific situations where there's a high risk of thrombosis, anticoagulation with drugs like warfarin may be considered, but this decision should be made on a case-by-case basis by a nephrologist 1. The current evidence does not support the use of Eliquis (apixaban) as a first-line treatment for patients with nephrotic syndrome, and instead emphasizes the importance of addressing the underlying cause of the condition and managing symptoms.
From the Research
Indication of Eliquis (Apixaban) in Patients with Nephrotic Syndrome
- Eliquis (apixaban) is indicated in patients with nephrotic syndrome for the prevention of thromboembolic events (TEs) 2, 3.
- Studies have shown that apixaban can reduce the risk of venous and arterial TEs in patients with nephrotic syndrome without increasing the risk of bleeding 2, 3.
- A retrospective study found that patients with nephrotic syndrome treated with apixaban had a reduced risk of TEs compared to those previously described in the literature, without an increased risk of bleeding 2.
- Another study found that no patients experienced TEs during apixaban treatment, while five patients had a minor bleeding episode 3.
Safety and Efficacy of Apixaban in Patients with Nephrotic Syndrome
- Apixaban has been shown to be safe and effective in patients with nephrotic syndrome, with a low risk of major bleeding and similar overall bleeding rates compared to previously published literature 3, 4.
- A study found that apixaban may serve as a reasonable alternative to warfarin in patients with severe renal dysfunction, with a lower risk of thrombotic and bleeding events 5.
- The use of apixaban in patients with advanced kidney disease has been evaluated, and the results suggest that it can be used safely and effectively in this population 4.
Clinical Considerations
- The decision to use apixaban in patients with nephrotic syndrome should be based on individual patient factors, including the risk of TEs and bleeding 2, 3.
- Patients with nephrotic syndrome should be closely monitored for signs and symptoms of TEs and bleeding while receiving apixaban therapy 2, 3.
- The dosage of apixaban should be adjusted according to the patient's renal function and other clinical factors 5, 4.