What are the considerations for using Eliquis (apixaban) in a patient with severe impaired renal function (eGFR of 10)?

Apixaban (Eliquis) Use in Patients with eGFR of 10 mL/min

Apixaban should not be used in patients with an eGFR of 10 mL/min due to increased bleeding risk and insufficient evidence supporting its safety and efficacy in this population. 1

Renal Function and Anticoagulation Considerations

Contraindications and Recommendations

• Apixaban is generally not recommended in patients with CrCl <15 mL/min who are not on dialysis 1, 2
• An eGFR of 10 mL/min falls into CKD stage 5 (GFR <15 mL/min), which is classified as kidney failure 2
• The European Heart Rhythm Association states that routine use of NOACs in patients with severe renal dysfunction remains to be established 2
• The FDA label for apixaban notes that clinical efficacy and safety studies did not enroll patients with end-stage renal disease (ESRD) or patients with CrCl <15 mL/min 3

Alternative Anticoagulation Options

For patients with eGFR of 10 mL/min requiring anticoagulation:

1. Warfarin (INR 2.0-3.0) may be considered as the preferred anticoagulant in this scenario 1

   • Requires close INR monitoring
   • Be aware of increased risk of calciphylaxis in end-stage renal disease 2

2. Unfractionated heparin (UFH) can be used as it does not require renal clearance 2

   • Particularly useful for acute anticoagulation needs

3. Low molecular weight heparin with anti-Xa monitoring may be considered in specific situations 2

   • Requires dose adjustment and careful monitoring

Bleeding Risk Assessment

Patients with severe renal impairment have significantly higher bleeding risk with all anticoagulants:

• Apixaban has been associated with increased bleeding risk in patients with ESRD, despite having the lowest renal clearance (27%) among NOACs 2
• A case report showed supratherapeutic apixaban levels and gastrointestinal bleeding in a hemodialysis patient even with reduced dosing 4
• Registry data have shown higher incidence of hospitalization or death from bleeding in dialysis-dependent patients started on off-label NOACs compared to VKA 2

Clinical Decision Algorithm

1. Assess need for anticoagulation:

   • Calculate CHA₂DS₂-VASc score (for AF)
   • Evaluate indication strength vs. bleeding risk

2. If anticoagulation is necessary:

   • First choice: Warfarin with target INR 2.0-3.0 with close monitoring
   • Second choice: Unfractionated heparin for acute situations
   • Avoid: Apixaban, other NOACs, fondaparinux (contraindicated with CrCl <20 mL/min) 2

3. If patient is transitioning to dialysis:

   • Reassess anticoagulation strategy after dialysis initiation
   • Consider that ongoing studies (RENAL-AF, AXADIA) may provide more guidance in the future 2

Important Caveats

• Avoid switching between anticoagulants in patients with severe renal impairment as this increases bleeding risk 1
• Regular monitoring of renal function is essential as fluctuations can significantly impact anticoagulant levels 1
• Pharmacokinetic studies show that even reduced doses of apixaban may lead to drug accumulation in severe renal impairment 4
• Consider left atrial appendage occlusion as a non-pharmacological alternative in high-risk patients 2

The decision to use any anticoagulant in a patient with eGFR of 10 mL/min must carefully weigh the thromboembolic risk against the substantially increased bleeding risk, with a strong preference for avoiding apixaban in this clinical scenario.