Direct oral anticoagulants (DOACS) are riskier than warfarin for patients with chronic kidney disease (CKD) and atrial fibrillation, according to new study findings published in the Clinical Journal of the American Society of Nephrology.

Among 3206 DOAC users and 3206 warfarin users (mean age 72), 1181 bleeding events and 466 ischemic strokes occurred over 7391 person-years of follow-up. Bleeding risk was just 1% higher for DOAC users with an estimated glomerular filtration rate (eGFR) of 60 mL/min/1.73 m2 or higher, but 23% higher for those with eGFR less than 60 mL/min/1.73m2, Jung-Im Shin, MD, PhD, of Johns Hopkins University in Baltimore, and colleagues reported. The investigators found no greater risk for ischemic stroke with DOACs, however. Analyses by individual drugs (e.g, dabigatran, rivaroxaban, and apixaban) corroborated the trends.

The findings lend support to current guidelines from the American Heart Association, American College of Cardiology, and European Society of Cardiology, “which suggest refraining from direct oral anticoagulant use for treatment of atrial fibrillation in advanced CKD, and raise safety concerns regarding the current US FDA labels. For now, we suggest caution in prescribing direct oral anticoagulants for patients with advanced CKD,” the authors stated.

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This real-world study was based on electronic health records from the Geisinger Health System. Among other study limitations, few patients with eGFRs below 30 mL/min/1.73m2 were included.

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Shin JI, Secora A, Alexander C, et al. Risks and Benefits of direct oral anticoagulants across the spectrum of GFR among incident and prevalent patients with atrial ibrillation. Clin J Am Soc Nephrol. doi: 10.2215/CJN.13811217