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The following is a summary of “Apixaban dosing in hemodialysis – can drug level monitoring mitigate controversies?” published in the October 2024 issue of Nephrology by Schietzel et al. 

Researchers conducted a retrospective study to investigate appropriate apixaban dosing in patients on hemodialysis amid inconsistent study results and recommendations. 

They analyzed pre-dialysis apixaban levels from patients at a tertiary care dialysis unit, comparing 2.5 mg once vs twice daily dosing. Mixed-effects models were used, adjusting for dialysis modality, standard Kt/V, ultrafiltration, and dialyzer characteristics. An exploratory analysis of bleeding events was conducted, and drug levels were compared to non-CKD reference populations taking 5 mg twice daily (standard dose). 

The results showed 143 drug levels from 24 patients, with a mean (SD) age of 64.7 (15.9) years (50% female) and a median (IQR) follow-up of 12.5 (5.5 – 21) months. Median (IQR) drug levels were 54.4 (< 40 – 72.1) ng/mL for 2.5 mg once daily and 71.3 (48.8 – 104.1) ng/mL for twice daily (P<0.001). Levels were below detection in 30% (once daily) and 14% (twice daily). Only dosing frequency was independently linked to higher drug levels (P=0.002). No accumulation was noted. Median (IQR) drug levels before bleeding (8 episodes) were higher: 111.6 (83.1 – 129.3) vs 54.8 (< 40 – 77.1) ng/mL (P<0.001). Antiplatelet therapy was used in 86% of bleeding cases vs 6% without (P<0.001). 

The study concluded that drug monitoring, even without established target ranges, could enhance patient safety and support individualized risk-benefit decisions by identifying extreme apixaban levels. 

Source: bmcnephrol.biomedcentral.com/articles/10.1186/s12882-024-03782-w#Abs1