People with irregular heartbeat due to a condition called atrial fibrillation, are often prescribed blood thinners to reduce the risk of blood clots that can cause a stroke.
But for those who are also on dialysis for kidney failure, the already-difficult choice of blood thinner can seem like a guessing game without a right answer.
Why does this happen?
Patients on dialysis are routinely excluded from clinical trials, which test utility and safety of treatments.
However, a new study published in Circulation shows that one anticoagulant, apixaban (also known as Eliquis), may be safer for this patient population.
The team studied patterns of apixaban use and associated outcomes in more than 25,000 Medicare beneficiaries as a research project.
During the study period, apixaban was increasingly used and about 1 in 4 new blood thinner prescriptions in 2015 were for apixaban.
The research shows that the risk of major bleeding was about 30% less for those on apixaban compared to warfarin.
A complicated calculation
If blood isn’t completely pumped out of the heart due to atrial fibrillation, it can pool into clots and cause a stroke.
This can lead clinicians to prescribe blood thinners to reduce the clotting risk.
The anticoagulation landscape for all patients continues to change as new agents, including apixaban, become more popular, while mainstay warfarin (also known as Coumadin) is still widely used in the general population.
However, warfarin is difficult to manage and comes with the risk of major bleeding.
The lead author says there’s uncertainty about whether adding dialysis to the mix means an anticoagulant is still a good idea for someone with Afib, given the safety and bleeding concerns.
Need for more data
Although clinical trials have investigated use and outcomes of anticoagulants in atrial fibrillation, the most common form of heart arrhythmia, their findings cannot be applied to people on dialysis in the same way as other patients.
The comorbidities and other worse outcomes associated with kidney failure and dialysis lead most researchers to exclude this population from clinical trials.
The team says these clinical outcomes data, while important, are only the first step.
“Atrial fibrillation is a pretty significant determinant of adverse outcomes in this population.”
“It’s a common problem in dialysis patients who generally have a lot of comorbidities. And the patients on dialysis who have Afib experience higher rates of stroke compared to patients with Afib who aren’t on dialysis.”
“The combination of dialysis with atrial fibrillation is a difficult one, but as we learn more from real-world data and clinical trials, we are hopeful that the decision-making will be better informed in the near future to the benefit of these patients.”
“These are the first data to show that apixaban is potentially safer than warfarin in dialysis patients with atrial fibrillation.”
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