Oral Anticoagulants for Potential Transplant Patients
The medical staff at the University of Iowa Organ Transplant Center issued the following advisory to referring physicians concerning the management of bleeding and reversal strategies for patients who might be on an organ wait list.
The article referenced in the letter can be found in the American Journal of Health-System Pharmacists.
Dear healthcare provider,
Patients may be inquiring about new “target specific” oral anticoagulant medications as they become more readily available and widely advertised. These products, the oral direct thrombin and factor Xa inhibitors, may offer advantages and it may be tempting to switch patients to these agents for ease of administration, safety, and to eliminate the need for fewer follow-up appointments for INR checks. These anticoagulants are appropriate for some patients, but for others they raise risks and concerns that need to be considered.
Specifically, it may not be advisable to choose these medications for renal transplant candidates (or other transplant candidates) waiting for organs on the deceased donor list. Several of these newer agents require an extended period for discontinuation prior to having surgery. Very limited data are available to guide the reversal of these newer agents in patients who need urgent surgery. Most of these new agents DO NOT have adequately tested, reliable agents to reverse the bleeding risk, therefore creating issues in patients requiring urgent transplant surgeries (Nutescu EA, Dager WE, Kalus JS, Lewin JJ 3rd, Cipolle MD.\. Management of bleeding and reversal strategies for oral anticoagulants: clinical practice considerations. Am J Health Syst Pharm. 2013 Nov 1;70(21):1914-29. doi: 10.2146/ajhp130243.).
If a transplant candidate is receiving one of these medications and an organ becomes available for them, we will not have the luxury of waiting up to 2 days for the effect of the drug to wear off and their transplant will likely be cancelled because of the risk of uncontrolled bleeding. Another thing you should be aware of: most of these newer anticoagulants are contraindicated or require dosing adjustments with renal insufficiency, so they may not be the best or even the most appropriate choice for renal failure patients.
Below is a list of common anticoagulation agents on the market with the recommended time of discontinuation necessary to minimize the bleeding risk. The list also includes a note as to whether or not there are precautions for their use in patients with renal dysfunction (i.e. kidney transplant candidates) and whether an agent for reversal is currently available.
We do not wish to interfere with the care of your patients in any way, but the use of these new oral anticoagulants in our waitlisted transplant candidates may interfere with their ability to receive a transplant safely. If you have any questions regarding your patient’s anticoagulation regimen please feel free to contact the University of Iowa Hospitals & Clinics Solid Organ Transplant office at (877-386-9109).
Alan Reed, MD MBA
Professor and Chief, Division of Transplant and HPB Surgery
Director, UI Organ Transplant Center
University of Iowa Health Care
200 Hawkins Drive, SE 427 GH
Iowa City, IA 52242-1086