DOAC dosing thresholds were set in trials using Cockcroft–Gault creatinine clearance, not eGFR. In small, older or lighter patients, eGFR can overstate kidney function and lead to overdosing, or understate it and prompt unnecessary reduction. For apixaban in AF, reduce to 2.5 mg twice daily only when two of three criteria are present: age 80 or over, weight 60 kg or less, serum creatinine 1.5 mg/dL (133 µmol/L) or higher. Off-label dose reduction increases stroke without reliably reducing bleeding.
- Calculate Cockcroft–Gault creatinine clearance using actual body weight
- Apixaban: reduce only with 2 of age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL
- Rivaroxaban: 15 mg daily when CrCl is 15–49 mL/min
- Recheck kidney function at least yearly, more often when CrCl is below 60
Why it matters
Unnecessary dose reduction is common in CKD and, as COMBINE AF shows, costs strokes.
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