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In reply—New Oral Anticoagulants in Elderly Adults With Chronic Kidney Disease

      We thank Dr Pazmiño for his comments on our article. Many of the new oral anticoagulants (NOAs) are excreted to a substantial extent by the kidney, and it is certainly necessary to consider dosage adjustments on the basis of the patient's estimated glomerular filtration rate. It is true that the occurrence of nonvalvular atrial fibrillation is increased in patients with advanced kidney failure, and use of NOAs has some appeal for this condition compared with other oral anticoagulants such as vitamin K antagonists (warfarin). However, we recommend great caution with the use of NOAs in patients with advanced renal failure because it can be extremely difficult to assess the appropriate safe and effective dosing regimen in these patients, and if serious bleeding occurs during NOA use, immediate reversal of the anticoagulant effects of NOAs can be problematic. To confirm our concern, a recent study by Chan et al
      • Chan K.E.
      • Edelman E.R.
      • Wenger J.B.
      • Thadhani R.I.
      • Maddux F.W.
      Dabigatran and rivaroxaban use in atrial fibrillation patients on hemodialysis.
      revealed that the use of dabigatran or rivaroxaban in patients undergoing hemodialysis was associated with a higher risk of hospitalization or death from bleeding when compared with warfarin. Such a risk may be further increased if patients with severe renal failure are elderly, because aging can impair the pharmacokinetics of many drugs and further expose the patient to an unintentional risk of bleeding.
      • Ponticelli C.
      • Sala G.
      • Glassock R.J.
      Drug management in the elderly adult with chronic kidney disease: a review for the primary care physician.

      References

        • Chan K.E.
        • Edelman E.R.
        • Wenger J.B.
        • Thadhani R.I.
        • Maddux F.W.
        Dabigatran and rivaroxaban use in atrial fibrillation patients on hemodialysis.
        Circulation. 2015; 131: 972-979
        • Ponticelli C.
        • Sala G.
        • Glassock R.J.
        Drug management in the elderly adult with chronic kidney disease: a review for the primary care physician.
        Mayo Clin Proc. 2015; 90: 633-645

      Linked Article

      • New Oral Anticoagulants in Elderly Adults With Chronic Kidney Disease
        Mayo Clinic ProceedingsVol. 90Issue 11
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          I read with interest the review article by Ponticelli et al1 on drug management in the elderly adult with chronic kidney disease (CKD) that was published in the May 2015 issue of Mayo Clinic Proceedings and agree with their recommendations. Of note, the section on oral anticoagulants does not include or comment on the 4 new oral anticoagulants (NOAs) that have been approved by the US Food and Drug Administration (FDA) over the past 5 years. The NOAs approved are dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and, recently, edoxaban (Savaysa).
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