Most dose-adjustment thresholds in DOAC labelling and trials were based on creatinine clearance calculated with the Cockcroft-Gault equation, which uses age, weight and serum creatinine. eGFR from CKD-EPI, which laboratories report, can differ substantially, especially in older, lighter patients.
Using eGFR can lead to overdosing in frail older people, and underdosing, which is common, removes much of the protection against stroke.
- Calculate Cockcroft-Gault creatinine clearance using actual body weight when choosing a DOAC dose.
- Recheck kidney function at least yearly, and more often if clearance is below 60 mL/min or the patient is unwell.
- Do not reduce the dose unless the patient meets the drug-specific criteria.
- Review DOAC choice and dose during any AKI episode.
Why it matters
Wrong DOAC doses in kidney disease are common and cause both bleeding and strokes.
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