Can apixaban (apixaban) be restarted in a 57-year-old male (YOM) with a history of atrial fibrillation (AFib) and improved impaired renal function, with an estimated glomerular filtration rate (eGFR) of 32, after an episode of acute kidney injury (AKI)?

From the Guidelines

Apixaban can be restarted in this 57-year-old male with atrial fibrillation and an eGFR of 32 following resolution of acute kidney injury, with a standard dose of 5 mg twice daily, as his eGFR is above 30 mL/min, according to the most recent guidelines 1. The decision to restart apixaban is based on the patient's improved renal function and the fact that apixaban has a more favorable bleeding risk profile and lower dependence on renal clearance compared to other direct oral anticoagulants 1. However, dose reduction to 2.5 mg twice daily would be necessary if he meets two of the following criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, as recommended by the guidelines 1. Before restarting, it's essential to ensure the AKI has fully resolved and renal function has stabilized, with regular monitoring of renal function recommended, particularly in the first few weeks after restarting therapy 1. Key considerations include:

• Apixaban's pharmacokinetics, with approximately 27% renal elimination, making it a suitable option for patients with moderate renal impairment 1
• The importance of monitoring renal function and adjusting the dose as needed to minimize the risk of bleeding complications 1
• The preference for apixaban over warfarin in patients with moderate renal impairment due to its more favorable bleeding risk profile and lower dependence on renal clearance 1
• The need for reassessment of anticoagulation strategy if the patient's renal function deteriorates further to an eGFR below 25-30 mL/min 1

From the Research

Apixaban Restart in Patient with Improved Renal Function

• The patient, a 57-year-old male with a history of atrial fibrillation (AFib), experienced an episode of acute kidney injury (AKI) with an initial estimated glomerular filtration rate (eGFR) of 6, which has since improved to 32.
• The decision to restart apixaban, a direct oral anticoagulant (DOAC), depends on various factors, including the patient's renal function and the risk of stroke or systemic embolism (SE).

Renal Function and Apixaban Use

• Studies have shown that apixaban can be used safely in patients with impaired renal function, including those with an eGFR < 30 ml/min/1.73 m2 2, 3.
• A study published in Frontiers in cardiovascular medicine found that apixaban reduced the risk of stroke/SE by 37% in patients with an eGFR < 30 ml/min/1.73 m2 2.
• Another study published in The Israel Medical Association journal found that apixaban was associated with a lower risk of mortality and composite outcomes compared to warfarin in patients with severe renal dysfunction (eGFR 15-30 ml/min/BSA) 3.

Apixaban Dosing and Renal Function

• The AUGUSTUS trial found that apixaban resulted in less bleeding and fewer hospitalizations than vitamin K antagonists, and the safety and efficacy of apixaban were consistent across different kidney function categories 4.
• A binational population-based study published in Kidney360 found that apixaban was associated with lower or similar risk of ischemic and bleeding outcomes compared to warfarin across different eGFR categories, including those with an eGFR < 30 ml/min/1.73 m2 5.

Considerations for Apixaban Restart

• Based on the available evidence, apixaban can be considered for restart in this patient with improved renal function (eGFR 32) and a history of AFib, taking into account the patient's individual risk factors and clinical circumstances 2, 3, 4, 5.
• However, it is essential to closely monitor the patient's renal function and adjust the apixaban dose accordingly, as recommended by the manufacturer and clinical guidelines.