Weekly blog - Coumadin in Dialysis Patients with Atrial Fibrillation

Great discussion today -- very nuanced and the blog may not do it justice:

The CCS guidelines 2012 focused update:

We suggest that such patients not routinely receive either OAC (Conditional Recommendation, Low-Quality Evidence) or ASA for stroke prevention in AF (Conditional Recommendation, Low-Quality Evidence). Values and preferences. This recommendation places a relatively higher weight on observational data linking warfarin and ASA use with mortality in patients on dialysis, and relatively lower weight on the potential for these agents to prevent ischemic stroke. Therapy with OACs or antiplatelet drugs may be appropriate for some patients with eGFR < 15 mL per minute (on dialysis) in whom there is a stronger preference for avoiding ischemic stroke."

A recent observational study (well done, large study, and one of many to show this association) done here @ McGill shows that there is no decrease in the rate of stroke with a significant increase in bleeding in patients on dialysis with or without coumadin

The associated editorial (here) calls for a randomized controlled trial.  I like this quote from that editorial which is also worth reading:

"It is ironic that we are routinely treating many patients with renal disease and atrial fibrillation every day with great uncertainty as to benefit or harm without their consent, and at the same time, major regulatory and ethical barriers exist that prevent efficient enrollment of patients into clinical trials that are needed to answer this (and other) important questions."

I searched CLINICALTRIALS.GOV and as of now there are no studies looking at coumadin in the dialysis population.  So experimental evidence is long from publication.

Clearly we need to think before getting out the pen (or throwing away the prescription pad) and have discussions with our patients that are transparent and evidence based.