Direct oral anticoagulant management in chronic kidney disease and atrial fibrillation
Creators: name: Emanuel, Subodhini
Publisher: name: University of Surrey
Year: 2025
Subjects: atrial fibrillation;chronic kidney disease;anticoagulants

description: Atrial fibrillation (AF) and chronic kidney disease (CKD) are becoming more prevalent in
description: modern society, particularly in developed countries, and their incidence increases in people
description: with hypertension, diabetes, and the elderly. Compared to people with each specific disease
description: alone, people with both AF and CKD have substantially greater rates of stroke,
description: cardiovascular events, and mortality.
description: Since 2010, four direct oral anticoagulants (DOACs) have been approved, shifting the
description: management of patients with AF. They have now become the new first-line therapy for
description: patients without valvular atrial fibrillation.
description: A systematic review and meta-analysis of studies reporting DOAC dosing, adherence, and
description: persistence in CKD and AF found that DOAC adherence and DOAC dosing were
description: suboptimal, and further that there was little literature regarding DOAC persistence in CKD
description: and AF.
description: An investigation of demographic and clinical factors associated with the prescribing of
description: DOACs was conducted in a large extract of UK primary care electronic records and it was
description: discovered that despite having the lowest mean age, people in the most deprived quintile
description: had the most comorbidities and were least likely to be anticoagulated. However, with respect
description: to correct DOAC dosing, the disparities in healthcare improved over five years between 2018
description: and 2022. Suboptimal monitoring was not associated with DOAC overdosing or
description: underdosing. Correct monitoring was best when conducted at six monthly intervals, and
description: worst at three monthly intervals. DOAC overdosing was associated with more
description: gastrointestinal bleeding. Dementia was the only factor associated with an increase in all
description: adverse events, including haemorrhagic stroke and any bleeding. Better adherence was
description: associated with the most deprived quintile, whilst better persistence was associated with the
description: least deprived quintile. Non-adherence and non-persistence were associated with adverse
description: events-haemorrhagic strokes, gastrointestinal bleeding, major bleeding, and any bleeding as
description: well as with ischaemic strokes. The likely reason for this is due to multiple of factors
description: including that non-adherence and non-persistence occurred after the adverse events and
description: that the patients involved in the adverse events had complex co-morbidities with frailty and
description: on other drugs which can lead to bleeding. However, we were not able to elicit statistically
description: significant results with this theory. Our findings agree with the new ESC 2024 guidelines of
description: the AF-Care pathway of personalised care, taking co-morbidities into account with DOAC
description: management