KISS: DOACs and Reduced Renal Function

NO

PHARMACEUTICAL INFLUENCE

NO PHARMACEUTICAL INFLUENCE

BNF & EHRA 2018

	CrCl > 50 ml/min	CrCl 30-49 ml/min	CrCl 15-29 ml/min	CrCl <15 ml/min
Apixaban: AF	5mg BD. Reduce dose to 2.5mg BD If 2 of: Age ≥ 80 Weight ≤ 60 kg Serum Cr ≥ 133	5mg BD. Reduce dose to 2.5mg BD If 2 of: Age ≥ 80 Weight ≤ 60 kg Serum Cr ≥ 133	Reduce dose 2.5mg BD.	Do not use.
Apixaban: Treatment of VTE*	Initially 10mg BD for first 7 days, then 5mg BD.	Initially 10mg BD for first 7 days, then 5mg BD.	Use with caution.	Do not use.
Rivaroxaban: AF	20mg OD.	Reduce dose 15mg OD.	Reduce dose 15mg OD.	Do not use.
Rivaroxaban: Treatment of VTE*	15mg BD for 3 weeks then 20mg OD.	15mg BD for 3 weeks, then consider reduced dose 15mg OD.	15mg BD for 3 weeks, then consider reduced dose 15mg OD.	Do not use.
Edoxaban: AF	60mg OD. Reduce dose 30mg OD if: Weight ≤ 60kg On P-gp inhibitors**	Reduce dose 30mg OD.	Reduce dose 30mg OD.	Do not use.
Edoxaban: Treatment of VTE*	Dose as above for AF (after 5 days of LMWH).	Reduce dose 30mg OD. (after 5 days of LMWH).	Reduce dose 30mg OD. (after 5 days of LMWH).	Do not use.
Dabigatran: AF	150mg BD. ↓ dose 110mg BD if: Age > 80 (consider reduced dose 110mg BD if age 75-79) High bleeding risk On verapamil	Consider Reduced dose 110mg BD depending on thrombosis-embolic/bleeding risk	Do not use.	Do not use.
Dabiagatran: Treatment of VTE*	Dose as above for AF (after 5 days of LMWH).	Reduce dose 110mg BD (after 5 days of LMWH).	Do not use.	Do not use.

Renal function monitoring:
- Minimum yearly and every 6 months if aged >75 years or frail.
- If CrCl < 60 mL/min, frequency of monitoring = the CrCl divided by 10; e.g. every 3 months if CrCl is 30 mL/minute.

*These refer to standard treatment doses for DVT and PE, usually for a minimum of 3 months, but the length of treatment should be specialist-led depending on VTE recurrence risk. *For prophylaxis of recurrent DVT/PE, lower doses may be recommended after a minimum 6 months of full treatment dose, but should be specialist-led and will be determined by the individual risk of VTE recurrence and bleeding risk (e.g. apixaban 2.5mg BD; rivaroxaban 10-20mg OD;) **P-gp inhibitors = ciclosporin, dronedarone, erythromycin, ketoconazole

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