The Safety of Direct Oral Anticoagulants Compared to Warfarin in Patients Hospitalized With Acute Kidney Injury.

BACKGROUND: Direct oral anticoagulants (DOACs) are preferred over warfarin for many indications, though their safety has not been well established in patients with acute renal impairment. OBJECTIVE: The purpose of this study was to evaluate the frequency of bleeding complications associated with DOACs compared with warfarin in patients admitted to the hospital with acute kidney injury (AKI). METHODS: This was a retrospective cohort study evaluating patients admitted to the Penn Medicine Lancaster General Hospital with a diagnosis of AKI from October 2017 through September 2021 and receiving therapy with oral anticoagulants. Comparing DOACs with warfarin, the primary endpoint was the percent frequency of composite major and minor bleeding during the admission and within 30 days of discharge. RESULTS: There were 112 hospitalization encounters included in the study. Of these, 42 (37.5%) patients were receiving warfarin and 70 (62.5%) patients were receiving DOAC therapy before admission. There was a higher frequency of the primary endpoint of bleeding in patients receiving DOACs as compared with warfarin, though this was not statistically significant (18.5% vs. 11.9%, respectively, P = 0.432). There were no differences between groups in the frequency of major bleeding, minor bleeding, or transfusions. Patients receiving DOAC therapy were more likely to experience anticoagulation-related readmissions or emergency department visits compared with patients on warfarin therapy (11.4% vs. 0%, P = 0.024). CONCLUSION AND RELEVANCE: Direct oral anticoagulants and warfarin were associated with statistically similar rates of bleeding in patients presenting with AKI. Further research is necessary to elucidate if DOACs are safer than warfarin in this patient population.

An observational study of ezetimibe in cardiac transplant recipients receiving calcineurin inhibitors.

BACKGROUND: Cardiac transplant patients are at risk for developing cardiac allograft vasculopathy, and dyslipidemia in this patient population has been associated with increased risk. Data evaluating the efficacy and safety of ezetimibe in this population are minimal. OBJECTIVES: The purpose of this study was to assess the effects of ezetimibe, alone or in combination with other lipid-lowering agents, in cardiac transplant recipients receiving calcineurin inhibitors (CNIs). METHODS: This study was a single-center retrospective chart review. Data on demographics, medications prescribed for dyslipidemia and prevention of transplant rejection, results of lipid panels, CNI blood concentrations, and adverse effects were extracted from medical records of cardiac transplant recipients who were prescribed ezetimibe, either alone or in combination with other lipid-lowering agents, and seen at least once in a 12-month period at a cardiac transplantation clinic of an 800-bed teaching hospital. RESULTS: There were 71 patients prescribed ezetimibe in whom a safety analysis was performed. Approximately 49% (n = 35) were included in the analysis for lipid lowering. Ezetimibe significantly decreased low-density lipoprotein cholesterol (LDL-C; 129 mg/dL vs 94 mg/dL, P < .0001), non-high-density lipoprotein cholesterol (non-HDL-C; 170 mg/dL vs 127.5 mg/dL, P = .0058), and total cholesterol (236 mg/dL vs 200 mg/dL, P < .0001). There was no significant change in HDL-C and triglycerides as compared with baseline. The proportion of patients achieving goal LDL-C < 100 mg/dL significantly increased from 11.5% at baseline to 60.5% after the addition of ezetimibe (P < .0001). Ezetimibe had no measurable effect on blood CNI concentrations or doses. Adverse effects were reported by 15.5% of patients (n = 11), with 4% (n = 3) of patients discontinuing therapy. The most common complaints were gastrointestinal intolerance and myalgia. CONCLUSIONS: Ezetimibe was associated with lower LDL-C in cardiac transplant recipients either as combination therapy in patients with elevated LDL-C or as monotherapy, with a low frequency of adverse effects.