| Recommendations for dosage of oral anticoagulants based on renal function | |
|---|---|
| Warfarin | |
| CrCl &lgt; 50 mL/min | Dose adjusted for INR 2.0-3.0 |
| CrCl 30-49 mL/min | Dose adjusted for INR 2.0-3.0 |
| CrCl 15-29 mL/min | No RCT data‡ |
| CrCl < 15 mL/min (or the patient is dialysis-dependent) | No RCT data¶ |
| Dabigatran | |
| CrCl &lgt; 50 mL/min | 150 mg bid* |
| CrCl 30-49 mL/min | Consider 110 mg bid in preference to 150 bid |
| CrCl 15-29 mL/min | No RCT data |
| CrCl < 15 mL/min (or the patient is dialysis-dependent) | No RCT data∥ |
| Rivaroxaban | |
| CrCl &lgt; 50 mL/min | 20 mg daily |
| CrCl 30-49 mL/min | 15 mg daily |
| CrCl 15-29 mL/min | No RCT data |
| CrCl < 15 mL/min (or the patient is dialysis-dependent) | No RCT data∥ |
| Apixaban | |
| CrCl &lgt; 50 mL/min | 5 mg bid |
| CrCl 30-49 mL/min | 5 mg bid (consider 2.5 mg bid)† |
| CrCl 15-29 mL/min | Very limited RCT data§ |
| CrCl < 15 mL/min (or the patient is dialysis-dependent) | No RCT data∥ |
ARISTOTLE, Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation; bid, twice daily; CrCl, creatinine clearance; INR, international normalized ratio; RCT, randomized clinical trial.
* Consider dabigatran 110 mg oral bid if age < 75 years.
† Consider apixaban 2.5 mg oral bid if 2 of the 3 following criteria are present: (1) age > 80 years; (2) body weight < 60 kg; or (3) serum creatinine > 133 mmol/L.
¶ Dose-adjusted warfarin has been used, but data regarding safety and efficacy are conflicting.
§ The ARISTOTLE trial did include patients with a CrCl as low as 25 mL/min, but this was a very small number of patients (1.5% of patients in the trial).
‡ Dose-adjusted warfarin has been used, but data regarding safety and efficacy are conflicting and might lean toward causing harm.
∥ 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.