As a clinical pharmacy specialist, it is important to address the safety of using fondaparinux (Arixtra) in renal patients with a creatinine clearance (CrCl) less than 30 mL/min. Fondaparinux is primarily used subcutaneously (SQ) for the treatment and prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE).
According to the 2018 American Society of Hematology guidelines, fondaparinux can be considered for patients with suspected or confirmed heparin-induced thrombocytopenia (HIT) who are stable and have normal kidney function. The therapeutic dosing of fondaparinux is weight-based, ranging from 2.5 — 5 to 10 mg per day. Routine monitoring is not typically required in clinical practice.
However, in the case of a patient with a CrCl less than 30 and thrombocytopenia who cannot receive heparin, the preferred option is argatroban. It is important to note that argatroban may NOT be available in certain regions, such as Egypt. In such cases, fondaparinux, although not typically recommended in renal patients with a CrCl less than 30 mL/min, can be considered as an alternative. Smaller-scale studies suggest that a reduced daily dose of 1.5 mg instead of the standard 2.5 mg may be appropriate in these patients. It is essential to emphasize that further research is needed to establish the safety and efficacy of fondaparinux in this specific patient population. Alternatively, if the patient does not have HIT but has a CrCl less than 30 mL/min, enoxaparin (Clexane) can be safely administered as an anticoagulant at a daily dose of 30 mg OR oral apixiban (Eliquis) 2.5 mg twice daily in a case of HIT.
REFERENCES
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Al-Shaer MH, Ibrahim T. Safety and Efficacy of Fondaparinux in Renal Impairment. J Pharm Technol. 2015;31(4):161-166. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5990183
Harder S. Renal profiles of anticoagulants. J Clin Pharmacol. 2012;52(7):964-975. Available at: https://accp1.onlinelibrary.wiley.com/doi/full/10.1177/0091270011409231
Samama MM. Use of low-molecular-weight heparins and new anticoagulants in elderly patients with renal impairment. Drugs Aging. 2011;28(3):177-193. Available at: https://www.frontiersin.org/articles/10.3389/fphar.2021.783104/full