Clinical question: In patients with end-stage kidney disease (ESKD) and venous thromboembolism (VTE), does apixaban have a lower bleeding risk and VTE recurrence than warfarin?
Background: A safe and effective therapy for VTE is needed for patients with ESKD due to their increased risk of both thrombosis and bleeding. High-quality data evaluating direct oral anticoagulants in ESKD is limited, especially in VTE. The authors sought to evaluate the safety and effectiveness of apixaban compared to warfarin in treating VTE in ESKD.
Study design: Retrospective cohort study
Setting: The United States Renal Data System (USRDS) includes all available Medicare Parts A, B, and D claims data for patients with chronic kidney disease and ESKD in the U.S.
Synopsis: Using the USRDS, authors identified 11,565 patients aged 18 and older who were newly initiated on either apixaban or warfarin between January 2014 and June 2018. Apixaban was associated with lower total major bleeding (HR, 0.81; CI, 0.7–0.94) and total clinically-relevant nonmajor bleeding (HR, 0.84; CI, 0.74–0.94) compared to warfarin. Recurrent VTE was not significantly different between the medications but trended toward lower rates in the apixaban group (HR, 0.83; CI, 0.69–1.002). Apixaban also has previously established benefits of no required bridging therapy and no need for therapeutic monitoring. These findings suggest apixaban offers several advantages in treating VTE in ESKD.
Limitations included the inability to control for initial anticoagulation during the index hospitalization, uncertainty whether patients received a full apixaban loading dose, and inability to capture recurrent VTE in a prolonged hospitalization using Medicare claims data.
Bottom line: In ESKD, apixaban has a lower bleeding risk than warfarin with similar VTE recurrence.
Citation: Ellenbogen MI, et al. Safety and effectiveness of apixaban versus warfarin for acute venous thromboembolism in patients with end-stage kidney disease: a national cohort study. J Hosp Med. 2022;17(10):809-18.
Dr. Leiner is an academic hospitalist at Richmond Veterans Affairs Medical Center and an assistant professor of medicine at Virginia Commonwealth University in Richmond, Va.