| Warfarin | Dabi- gatran | Riva- roxaban | Apixaban |
|---|---|---|---|
| GFR > 60 mL/min | |||
| Dose adjusted for INR 2.0-3.0 | 150 mg bid or 110 mg bid | 20 mg daily | 5 mg bid |
| GFR 50-59 mL/min | |||
| Dose adjusted for INR 2.0-3.0 | 150 mg bid or 110 mg bid | 20 mg daily | 5 mg bid |
| GFR 30-49 mL/min | |||
| Dose adjusted for INR 2.0-3.0 | 150 mg bid or 110 mg bid | 15 mg daily | 5mg bid (for GFR > 25 mL/min only) Consider 2.5 mg bid† |
| GFR 15-29 mL/min (not on dialysis) | |||
| No RCT data‡ | No RCT data◊ | No RCT data♦ | 5mg bid (forGFR > 25 mL/min only) Consider 2.5 mg bid† |
| GFR < 15 mL/min (not on dialysis) | |||
| No RCT data‡ | No RCT data♦ | No RCT data♦ | No RCT data |
bid, twice daily; CHADS2, Congestive Heart Failure, Hypertension, Age > 75, Diabetes Mellitus, and Prior Stroke or Transient Ischemic Attack score; GFR, glomerular filtration rate; INR, international normalized ratio; RCT, randomized clinical trial.
† Patients with serum creatinine ≥ 133 µmol/L (1.5 mg/dL) who are also ≥ 80 years or whose body weight ≤ 60 kg, should receive a reduced dose of apixaban 2.5 mg twice daily.
‡ Dose adjusted warfarin has been used, but observational data regarding safety and efficacy is conflicting (see text).
◊ Modelling studies suggest that dabigatran 75 mg bid might be safe for patients with GFR 15-29 mL/min, but this has not been validated in a prospective cohort.
♦ No published studies support a dose for this level of renal function; product monographs suggest the drug is contraindicated for this level of renal function.