1Canberra Hospital, Phillip, Australia

Background: There are safety and efficacy concerns surrounding use of warfarin use in haemodialysis patients. Efficacy of warfarin for stroke prevention in dialysis patients is controversial. Warfarin is associated with complications such as haemorrhage and calciphylaxis. Apixaban is an alternative anticoagulant but currently there is no outcome data in patients with eGFR of <25ml/min. Since 2014, FDA labelling has permitted the use of apixaban in this group but such use is off-label in Australia. Dialysis patients with atrial fibrillation (AF) or a clotted arteriovenous fistula (AVF) may fit the PBS criteria for Apixaban funding.
Aim: To monitor the efficacy and safety of Apixaban in chronic kidney disease patients.
Methods: All patients with eGFR <25 mL/min/173m2 prescribed apixaban within the renal unit eligible for inclusion in the monitoring study. Patients provided informed consent for off-label use of apixaban as part of routine clinical care. Trough anti-Xa levels were measured 1 week post commencement.
Results: During the monitoring period from 1/1/2018 to 11/4/2018 a total of 7 patients were prescribed Apixaban. The most common reason given by the prescriber was labile international normalized ratio (INRs). Six of the patients were haemodialysis dependant and 5 were anti coagulated to maintained fistula patency. The anti-Xa concentration ranged between 35 to 99 ng/ml (laboratory target therapeutic range 50-200 ng/ml) (table 1). Due to sample timing issues a trough level was not available for one patient. All patients tolerated Apixaban without apparent adverse events. There were no episodes of excess bleeding or thrombosis.
Conclusion: In this small observational study, apixaban use appears to be safe with a relatively narrow range of anti-Xa levels noted for a given dose of apixaban.

Obtained medical degree from India and came to Australia to pursue further education. Finished his Basic Physician Training and currently working as a renal advance trainee (second year) at Canberra Hospital. Interested in the transplant medicine and general nephrology.

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