Effectiveness and Safety of Direct Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation and Venous Thromboembolism Treatment in End-Stage Renal Disease Patients at Trillium Health Partners

Abstract

Background/objectives: Patients with end-stage renal disease (ESRD) make up a complex population with both a higher risk of stroke and thromboembolism (VTE) and a higher risk for bleeding. Although historically managed with warfarin, evidence now suggests a potential benefit of direct oral anticoagulants (DOACs). As such, this study aimed to assess the effectiveness and safety of DOAC use in ESRD patients at Trillium Health Partners (THP), and compare this to available literature to determine if our patients are being safely and appropriately managed. Methods: Electronic records from Epic were retrospectively reviewed from October 10, 2020 to November 30, 2023 to identify patients receiving dialysis and being treated with a DOAC for the purposes of stroke prophylaxis in atrial fibrillation (AF) or treatment for VTE. Primary efficacy outcomes included recurrent stroke or VTE while receiving DOAC therapy. Safety outcomes assessed the occurrence of major and minor bleeding events. Results: A total of 52 patients were included in the study, with the majority (92.3%) receiving anticoagulation for stroke prophylaxis in AF. 92.3% received apixaban, 5.8% received edoxaban, and no patients received rivaroxaban or dabigatran. During the 3 years of follow up, 2 patients (3.8%) experienced an ischemic stroke and 1 patient (1.9%) experienced a recurrent VTE. The most common event was a bleed, with an incidence of 59.6% for any bleed, and 17.3% for major bleeds. Conclusion: Given the small population size, firm conclusions regarding the effectiveness and safety of apixaban for stroke prophylaxis could not be drawn. However, comparison to current literature suggests a similar incidence of stroke and bleeding as warfarin users in the same population. Very few patients in this study received VTE anticoagulation or used other DOACs. Although conclusions could not be made, the results of this study highlight a need for further studies in this clinical area.