Use of Anticoagulation in Patients on Haemodialysis: Patterns and Safety Outcomes

Background: Conflicting international guidelines regarding direct oral anticoagulant (DOAC) use in haemodialysis patients have created clinical uncertainty. The U.S. Food and Drug Administration (FDA) recommends apixaban 5 mg twice daily, with a dose reduction to 2.5 mg if age >80 years or weight <60 kg. In contrast, the European Medicines Agency advises against apixaban in patients with creatinine clearance <15 ml/min. This audit assessed anticoagulant prescribing practices and safety outcomes in an Irish haemodialysis unit Methods: This retrospective review included all haemodialysis patients at a tertiary hospital. Anticoagulated patients were analysed for drug, dose, indication, and bleeding events requiring hospitalisation in past 6 months. For patients on warfarin, INR values over 3 months were reviewed to calculate time in therapeutic range (TTR). Poor control was defined as TTR <65%. Results: Of 126 patients, 32 (25.4%) were on anticoagulation. Median age was 75.5 years and 71.9% were male. Apixaban was prescribed in 29 (90.6%), primarily for atrial fibrillation (89.6%); two had VTE, and one had both. Five (17.2%) received apixaban 5 mg twice daily, four of whom were obese (median weight 97 kg). Three patients were prescribed warfarin, two with mechanical valves and one with VTE. Mean TTR was low at 35.2%. Four patients (12.5%) experienced bleeding events requiring hospitalisation, all of whom were prescribed apixaban 2.5 mg BD. Conclusion: This study highlights the prevalent use of apixaban in patients undergoing haemodialysis. Apixaban was most commonly prescribed at a reduced dose of 2.5 mg twice daily, with higher dosing more common in patients with increased body weight. All bleeding events occurred in patients on lower dose apixaban. Warfarin use was associated with poor anticoagulant control. These findings emphasise the need for more prospective studies to guide anticoagulation practices in haemodialysis patients.