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Primary Care Hacks

Direct Oral Anticoagulant Dosing for Stroke Prevention in People with Nonvalvular Atrial Fibrillation and Renal Impairment

Guidelines presents Primary Care Hacks, a series of clinical aide-memoires across a range of topics. Developed by Dr Kevin Fernando, Primary Care Hacks aim to provide a quick and easy resource for primary healthcare professionals and ultimately help improve patients' lives.

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Direct Oral Anticoagulant Dosing for Stroke Prevention in People with Nonvalvular Atrial Fibrillation and Renal Impairment

Latest Update

30 January 2023: since initial publication, prescribing note 5 has been updated to include further information on calculating creatinine clearance.

This Medscape UK Primary Care Hack is intended to help guide primary healthcare professionals in the choice and dose of medication for stroke prevention in people with nonvalvular atrial fibrillation and renal impairment.

Expand the table for full view. Find a downloadable PDF of the table at the end of the article.

 ≥50 ml/min30–49 ml/min15–29 ml/min<15 ml/min
Apixaban15 mg bd. Check ABC rule: age ≥80 years; bodyweight ≤ 60kg; creatinine ≥133 mcmol/l

If ≥2 factors present, reduce dose to 2.5 mg bd

2.5 mg bd 
Dabigatran2150 mg bd. Check: age ≥80 years and drugs: verapamil. If either present: 110 mg bd

If aged 75–80 years, CrCl 30–50 ml/min, GORD, or increased risk of bleeding, consider reduced dose of 110 mg bd

Edoxaban3[A]60 mg od. Check: weight ≤60 kg and drugs—ciclosporin, dronedarone, erythromycin, or ketoconazole

If either present: 30 mg od

30 mg od 
Rivaroxaban420 mg od (take with or after food to increase bioavailability)15 mg od (take with or after food to increase bioavailability) 
KeyNo dose adjustment recommended
Dose adjustment recommended
Not recommended/contraindicated
Abbreviations: ABC: age, bodyweight, and creatinine; bd: twice daily; CKD: chronic kidney disease; CrCl: creatinine clearance; DOAC: direct oral anticoagulant; eGFR: estimated glomerular filtration rate; GORD: gastrointestinal reflux disease; IT: information technology; MHRA: Medicines and Healthcare products Regulatory Agency; od: once daily

[A] CrCl over 80 ml/min: re-evaluate treatment choice and consider alternative. A trend towards decreasing efficacy with increasing creatinine clearance has been observed compared to well-managed warfarin with edoxaban5.

Table based on summaries of product characteristics and the author’s clinical experience and appraisal of the literature.

Click on the link below for a downloadable PDF of the Primary Care Hack.

Direct Oral Anticoagulant Dosing for Stroke Prevention in People with Nonvalvular Atrial Fibrillation and Renal Impairment

Prescribing Notes

  1. A MHRA drug safety update published during 2020 re-emphasised that those on DOACs are at increased risk of bleeding, particularly older people with renal impairment. Specific DOAC reversal agents are available for dabigatran, apixaban, and rivaroxaban
  2. DOACs are not ‘fire and forget’ drugs; renal and liver monitoring and assessment of concordance should be undertaken regularly. Frequency of monitoring and assessment will be dependent on individual patient characteristics, but should be at least annual
  3. Useful rule of thumb: if CrCl is in the 30s, recheck CrCl 3-monthly; if CrCl is in the 20s, recheck CrCl 2-monthly, and so on. See for further advice regarding DOAC monitoring
  4. Do not use eGFR to assess the degree of renal impairment; eGFR was originally intended for the diagnosis and staging of CKD, whereas CrCl should be used for drug dosing, especially high-risk drugs or those with a narrow therapeutic index, such as DOACs
  5. CrCl is calculated automatically within many GP IT systems. There are also online calculators and many free apps (e.g. MedCalX). Use actual bodyweight from the last 12 months in these calculations up to bodyweight 120 kg or BMI 40. Use adjusted bodyweight if individuals are above these thresholds6
  6. As with warfarin, patients on DOACs should carry patient alert cards supplied by the hospital, dispensing chemist, or GP practice. These are included within the patient information materials in each DOAC box
  7. Healthcare professionals are advised to take caution when deciding to prescribe these anticoagulants to patients with other conditions, undergoing other procedures, and on other treatments, which may increase the risk of major bleeding. The following contraindications now apply to all new oral anticoagulants, for all indications and doses:
    • a lesion or condition, if considered a significant risk factor for major bleeding—see the sections on contraindications in the relevant summaries of product characteristics for further information
    • concomitant treatment with any other anticoagulant agent—see the sections on contraindications in the relevant summaries of product characteristics for further information.
Primary Care Hacks are developed by Dr Kevin Fernando, GP Partner, North Berwick Health Centre; GP with special interest in CVRM and medical education; Content Advisor for WebMD Medscape Global and UK. This Primary Care Hack is based on the author's interpretation of relevant summaries of product characteristics. Primary Care Hacks are for information for primary healthcare professionals in the UK only. They bring together currently available recommendations and/or prescribing information and indications for therapeutics licensed within Great Britain. Licensed indications and/or prescribing information for Northern Ireland may differ. You are advised to review local licensed indications before prescribing any therapeutic. Primary Care Hacks are reviewed intermittently to ensure the information is up to date at the time of publication. Primary Care Hacks are independently produced by WebMD Medscape UK Ltd (WebMD, LLC) and have not been created in conjunction with any guideline or prescribing body.