Oral anticoagulants in patients with chronic renal insufficiency

Background: Approximately one third of all patients with atrial fibrillation also have chronic kidney disease (CKD) which increases the risk for thromboembolic events and bleeding. Under therapy with vitamin K antagonists the risk of bleeding in this patient population is increased and cardiovascular calcification can also be accelerated in dialysis patients. New (direct) oral anticoagulants (NOAC) are increasingly being used worldwide for prophylaxis of stroke in non-valvular atrial fibrillation and are also administered to patients with limited renal function for prophylaxis and treatment of thrombosis.; Objectives: These NOACs have common pharmacokinetic characteristics, such as rapid onset of action, a short half-life time and a predictable effect, therefore, routine laboratory monitoring is not necessary in comparison to vitamin K antagonists; however, a side effect of all NOACs is an increased tendency for bleeding and a prolonged bleeding time.; Results: The incidence of intracranial bleeding, the most serious side effect of treatment with anticoagulants, shows a twofold to threefold decrease under treatment with NOACs when compared to warfarin. In the registration studies gastrointestinal bleeding occurred more often in patients with NOAC treatment, hence, careful prescription and dosing is necessary in patients with a history of bleeding or comedications which influence blood coagulation or interfere with the metabolism of NOACs.; Discussion: As all currently available NOACs are at least partially excreted by the kidneys, progressive CKD can lead to an accumulation of the drugs. Due to the lack of routine monitoring overdosing or underdosing might occur. Currently no antagonist for new oral anticoagulants is available; therefore a symptomatic treatment is recommended in cases of bleeding. © 2014, Springer-Verlag Berlin Heidelberg.