A recent small report from the
MGH group found that apixaban can be used in ESRD HD patients with
calciphylaxis who require anticoagulation.
It is well know that warfarin is a risk factor for calciphylaxis. Most
of the patients on HD that require anticoagulation are on warfarin. Given the
risk of calciphylaxis, the concept of changing over to a factor Xa inhibitor
was used in this study to see if that be used for replacement of warfarin. It was a retrospective study at a single
center and they found 20 patients who were on dialysis who were on apixaban
following a diagnosis of calciphylaxis. 27% of the drug is renally
excreted and hence not a bad choice for an ESRD patient.
There are although
no trials of this agent on ESRD on dialysis and specifically not in
calciphylaxis patients. A large retrospective trial did show that use of
apixaban compared to warfarin was associated with less bleeding in ESRD
patients and less stroke risk
and mortality with 5mg BID dosing.
While the study really highlighted that the switch from
warfarin to apixaban was ok and there
were no significant bleeding and clotting episodes, there were some additional
surprise findings. What was surprising to me was that the majority of the
patient got better with their calciphylaxis part. The cohort that got apixiban
had a lower mortality compared to the established published rates of patients
with calciphylaxis not on apixiban.
Have the investigators just stumbled upon a potential
treatment for this deadly disease? Given calciphylaxis has a component of TMA
and having them on an anticoagulant that doesn’t inhibit vitamin K might be
beneficial. The question remains that
would you start apixiban in someone with calciphylaxis who was not on
anticoagulation?
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