Dabigatran
Rivaroxaban
Apixaban
Edoxaban
Prodrug
Active drug
Active drug
Active drug
Direct Direct Direct Direct
80% 33% 27% 50%
p.o. p.o. p.o. p.o.
2–3h 2–4h 3–4h 1–2h
12–14h
7–12h
8–14h
10–14h
Medium Medium Medium Medium AE Anticoagulant effect
AT Antithrombin
FPX Fondaparinux
LMWH Low molecular
weight heparin
UFH Unfractionated
heparin
VKA Vitamin K antagonist
Dabigatran Anti-Xa Anti-factor Xa
activity
aPTT Activated
prothrombin time
FPX Fondaparinux
INR International
normalised ratio
LMWH Low molecular
weight heparin
od Once daily
UFH Unfractionated
heparin
VKA Vitamin K antagonist
Rivaroxaban
Apixaban
Edoxaban
Regular dosage
Not recommended
Regular dosage
Not recommended#
Not recommended
Not recommended
2 x 75mg/day
((10mg od))*
(2x5mg/d)
> 80y or < 60kg
reduced dosage
Contraindicated
(2.5mg twice daily)*
Outside the setting of elective joint
arthroplasty, meaningful subgroup analyses
of patients with CKD are rare. Therefore,
recommendations derived from joint replacement
surgeries are considered references for
postoperative VTE prevention also in other
indications.
Many of those – elderly – patients with CKD
undergoin g surgery are on long-term
anticoagulation therapy prior to the operation
due to AF or VTE. Nowadays, most of these
patients receive DOACs. Yet, there still is a
relevant proportion of patients treated with VKA
for these indications or others. Although minor
procedures can be performed in most patients
while on trough levels of DOACs or in the lower
part of the therapeutic INR-range, major surgeries
or interventions with an increased risk of
haemorrhage require normal hemostasis. For
DOACs an interruption for 2–5 days (Table 2)
depending on the specific DOAC as well as on
renal function seems to be a safe strategy.
Bridging of VKA anticoagulation by LMWH in the
context of AF has recently become a matter of
discussion. 15 Yet, it needs to be stressed that in
patients with sRI or ERD, having a clear cut
indication for anticoagulation therapy, bridging
via application of UFH may be less convenient,
but safer than the use of LMWH. Postoperative
Not recommended
((30mg od))*
anticoagulation in these patients may be initiated
with a prophylactic dose for some days before
– stepwise – escalation to the therapeutic dose,
depending on the postoperative bleeding risk.
Full dose anticoagulation therapy in
patients with CKD and VTE
Prospective randomised trials in general
populations with VTE have demonstrated that
anticoagulation therapy significantly decreases
recurrent VTE to a larger extend than it increases
hemorrhagic complications. 6 This beneficial
effect of treatment has been confirmed in
observational studies and registries. In large
registration studies patients with acute VTE (or
AF) and mRI have been included and subgroup
analysis demonstrated a comparable ‘net-benefit’
of therapeutic anticoagulation with numerically
higher rates of thromboembolic events and
bleeding complications compared with patients
with a GFR >60ml/min. 5-7 However, patients with
sRI or CHD were largely excluded.
Thus, prospective evidence as well as
systematic reviews and meta-analyses for patients
suffering from sRI or ESRD/CHD and acute VTE
are not available. However, tens of thousands of
patients with AF and CHD treated with warfarin
have been analysed with heterogeneous results. 6,17
Thus, any clear benefit of VKA in the CHD
21
HHE 2018 | hospitalhealthcare.com
As long as GFR
is >30ml/min,
standard dosages
of LMWH or
most DOACs can
safely be applied