Apixaban May be Better Option in Patients with CKD and AFib

BOSTON — Apixaban (Eliquis) may be better than warfarin (Coumadin) for lowering the incidence of systemic embolism, stroke, and major bleeding in patients with stage 4 or 5 chronic kidney disease (CKD) and atrial fibrillation (Afib), a meta-analysis found.

Among patients with CKD and Afib, apixaban had a significantly lower prevalence of major bleeding and stroke or systemic embolism (odds ratio 0.64, 95% CI 0.51-0.81) versus warfarin (OR 0.50, 95% CI 0.42-0.59), reported Rebaika Chopra, MD, of the Icahn School of Medicine in Mount Sinai in New York City, and colleagues at the National Kidney Foundation Spring Clinical Meeting.

Clinical trials assessing the safety and efficacy of warfarin versus apixaban in the setting of Afib generally have not included patients with end-stage renal disease (ESRD) or stage 4 or 5 CKD, the investigators noted.

Currently, there are no guidelines for anticoagulants in dialysis and CKD with creatinine clearance <30 mL/1.73 m²/min, noted Chopra. “So, choosing an AC [anticoagulant] in this population is provider dependent, and still many physicians prefer using warfarin. This paper emphasizes that apixaban is safer than warfarin when compared for bleeding risk and stroke risk,” Chopra told MedPage Today.

The researchers evaluated 7,598 patients on warfarin and 2,840 on apixaban across five retrospective cohort studies.

Using Google Scholar, ScienceDirect, PubMed, and Cochrane, they selected randomized clinical trials comparing the outcomes between the use of warfarin versus apixaban for Afib among patients with CKD. Using the inverse variance and random-effects method, the effect size of each investigation was pooled and computed together to calculate an OR.

Other data from a sub-analysis of patients with ESRD on hemodialysis also showed no difference with regard to incidence of stroke or systemic embolism with an OR 0.20 (95% CI 0.04-1.05), and a significant decline in incidence of major bleed with an OR 0.41 (95% CI 0.23- 0.75).

Limitations of the analysis included the fact that it included retrospective studies, making it subject to selection bias. Also, different doses of apixaban were used but not compared, and some studies were conducted at a single center.

“Based on the nature of our data, we cannot determine the rates of adherence in the apixaban group, the time in therapeutic training range in the warfarin group, and if patients were receiving heparin during dialysis sessions,” Chopra noted.

Although similar findings were found for patients on hemodialysis, the incidence of systemic embolism or stroke were not statistically significant because of low power, and will warrant further investigation for verification, Chopra’s group stated.