Utilization of direct‐acting oral anticoagulation in solid organ transplant patients: A national survey of institutional practices

Abstract

The safety and efficacy of direct‐acting oral anticoagulants (DOACs) and reversal strategies are not well established in the solid organ transplant population. This was a survey of pharmacists to assess DOAC and urgent reversal practices among adult transplant programs in the United States. A 27‐question survey was distributed to members of transplant pharmacy organization listservs between 5/28/19 and 6/30/19. A total of 115 responses were received from kidney (43.5%), heart (20.0%), lung (18.3%), liver (13.9%), and pancreas (4.4%) transplant programs. DOAC use prior to transplant was mostly prohibited in thoracic programs (77.3%) but more permissive in kidney transplant programs (64.0%). If permitted, apixaban (57.8%) was most preferred. At transplant surgery, reversal of DOAC was performed “as needed” (20.9%) or was not routine (18.3%). DOAC use post‐transplant was more permissive (94.3%). A majority of responders follow FDA recommended dosing in the setting of drug‐drug interactions (51.1%). Major factors influencing DOAC prescribing decisions included renal function, drug‐drug interactions, and insurance. High clinical practice variability exists regarding DOAC utilization and urgent reversal strategies in pre‐, peri‐, and post‐transplant stages. While more research is needed to refine the clinical landscape, many institutions are using DOAC therapy under the perception that they pose a similar risk of bleeding compared to a non‐transplant population.