POS-570 ATRIAL FIBRILLATION AND HAEMODIALYSIS: AN AUDIT OF ANTI-COAGULATION PRESCRIBING IN AN IRISH HOSPITAL.

Abstract

The objective of this audit was to evaluate prescribing of anti-coagulants for atrial fibrillation in haemodialysis patients in St. Vincent’s University Hospital. The prevalence of AF is between 8 and 34 percent in patients on haemodialysis1. End stage renal disease patients were excluded from key trials evaluating direct-acting oral anticoagulants (DOACs) in AF. Nevertheless when compared to warfarin DOACs have similar or superior efficacy, less bleeding risk, and more predictable pharmacokinetic and pharmacodynamic properties2. American Heart Association guidelines have altered to reflect this and now recommend apixaban in this patient group. Patients were included if prescribed warfarin or any DOAC for the indication of atrial fibrillation on September 1st 2020. Patients were excluded if actively awaiting transplant. Patient characteristics including age, sex, weight, anti-coagulant, CHA2DS2VASc score, HAS-BLED score, INR, concurrent antiplatelet, anticoagulant on dialysis, duration of anticoagulation and bleeding events during that time were recorded. Data was collected from SVUH Clinical Portal admission records and the EMED renal database. Data analysis was completed using SPSS. Eleven patients met inclusion criteria (Table 1). Seven patients were prescribed apixaban and four warfarin. No other DOACs were prescribed. Of those patients prescribed warfarin the percentage of INR values in the sub and supra-therapeutic ranges varied from 22-38% and 2-13% respectively. One patient in the DOAC group had a recorded bleed (GI, non-fatal requiring transfusion) event and one patient was prescribed an inappropriately high dose of apixaban. View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Patients with ESRD possess both a prothrombotic state predisposing to a high risk of thromboembolism and a coagulopathy with an increased tendency for bleeding3, 4. Prudence is required when deciding whether or not to anti-coagulate5. When anticoagulation is necessary the preferred choice is Apixaban, prescribed at the appropriate dose. The CHA2DS2VASc and HAS-BLED scores are useful guides. This audit identified four patients where a switch to apixaban may be appropriate and one patient where the apixaban dose should be reduced. This audit is too small to comment on risk of bleeding events, although it is noted that one patient had a recorded non-fatal bleed event requiring hospitalisation.