What is the preferred oral anticoagulant (OAC) for patients with Chronic Kidney Disease (CKD) stage 4, comparing Eliquis (apixaban) to other Direct Oral Anticoagulants (DOACs)?

From the Guidelines

Apixaban (Eliquis) is the preferred oral anticoagulant for patients with CKD stage 4 (severe renal impairment with eGFR 15-29 mL/min). For these patients, the recommended dose of apixaban is 2.5 mg twice daily if they also meet at least one of the following criteria: age ≥80 years or body weight ≤60 kg, as supported by the latest guidelines and studies 1. If they don't meet these additional criteria, the standard dose of 5 mg twice daily can be used. Apixaban is preferred over other DOACs like rivaroxaban, dabigatran, and edoxaban in CKD stage 4 because it has the least renal clearance (approximately 27%) among DOACs, making it safer in severe kidney disease, as shown in a study comparing the renal clearance of different DOACs 1.

Some key points to consider when prescribing apixaban to patients with CKD stage 4 include:

• Clinical data suggests apixaban maintains a favorable efficacy and safety profile in this population, with reduced risk of major bleeding compared to warfarin while still providing effective stroke prevention 1.
• Regular monitoring of renal function is essential, as further deterioration to CKD stage 5 (eGFR <15 mL/min) or dialysis may require reassessment of anticoagulation strategy.
• Patients should be advised to maintain consistent intake of apixaban with or without food and avoid missing doses to ensure stable anticoagulation.
• The use of apixaban in patients with CKD stage 4 is supported by observational studies and meta-analyses, which have shown its effectiveness and safety in this population 1.

Overall, apixaban is a safe and effective option for patients with CKD stage 4, and its use is supported by the latest guidelines and studies 1.

From the Research

Comparison of Eliquis (Apixaban) with Other Oral Anticoagulants (OACs) for CKD Stage 4

• The efficacy and safety of apixaban compared to warfarin in patients with stage 4 and 5 Chronic Kidney Disease (CKD) have been evaluated in several studies 2, 3, 4.
• Apixaban has been found to have a similar efficacy to warfarin for the prevention of stroke, systemic embolization, and recurrent venous thromboembolism, with a potentially better safety profile concerning the occurrence of bleeding 2, 3.
• A systematic review and meta-analysis of direct oral anticoagulants (DOACs) vs warfarin in patients with CKD or dialysis patients found that DOACs significantly reduced the risk of stroke, systemic embolism, or venous thromboembolism by 22% and major bleeding by 17% compared to warfarin 5.
• Apixaban was associated with a significantly better risk reduction of stroke, systemic embolism, or venous thromboembolism (25% risk reduction) and major bleeding (35% risk reduction) than warfarin 5.

Considerations for CKD Stage 4 Patients

• The choice of anticoagulant for patients with CKD stage 4 should take into consideration the pharmacokinetics of the drugs and patient characteristics 6.
• DOACs, including apixaban, are preferred in CKD stages 1 to 3, but the data are limited for advanced stages 6.
• Warfarin remains the first-line treatment in end-stage renal disease, although the decision to use or not to use anticoagulation is strictly individualized 6.

Safety and Efficacy of Apixaban in CKD Stage 4

• A retrospective cohort study found that patients with advanced CKD taking apixaban had similar bleeding rates at 3 months compared to those taking warfarin, but those who continued therapy had higher major bleeding rates with warfarin between 6 and 12 months 4.
• Another study found that apixaban was associated with a lower risk of major bleeding compared to warfarin in patients with advanced CKD or end-stage renal disease 3.