DIRECT ORAL ANTICOAGULANTS (DOAC) RENAL DOSE

APIXABAN DABIGATRAN EDOXABAN RIVAROXABAN

CrCl >95 mL/min:
CrCl ≥30mL/min: Not Recommended (Ref: Uptodate)
5mg BD or CrCl ≥50 mL/min: CrCl ≥50 mL/min:
Prevention of 150mg BD CrCl >50-95 mL/min: 20mg daily
60mg daily (B.W.>60kg)
Stroke and For patients with ≥2 of the following: 30mg daily (B.W.≤60kg)
Systemic Age≥80; B.W.≤60kg; SCr ≥133μmol/L CrCl 30-50 mL/min:
2.5mg BD 150mg BD or 110mg BD
Embolism in (based on individual assessment^) CrCl 15-50 mL/min or CrCl 15-49 mL/min:
Patients with
CrCl 15-30 mL/min: concurrent P-gp inhibitors∆: 15mg daily
CrCl 15-29 mL/min:  75mg BD (Ref: Uptodate) 30mg daily
Note: unless patient receiving concomitant P-gp
Non-Valvular 2.5mg BD inhibitor, then avoid concurrent use (Ref: Uptodate)
 Contraindicated (Ref: Drug Insert)
AF CrCl <15 mL/min: CrCl <15 mL/min: CrCl <15 mL/min: CrCl <15 mL/min:
 Not Recommended (Ref: Drug Insert) Contraindicated Not Recommended Not Recommended
 “Might Be Reasonable” (Ref: 2019 AHA/ACC/HRS)

CrCl ≥50 mL/min: CrCl >50 mL/min: CrCl ≥50 mL/min:

Following 60mg daily (B.W.>60kg) 15mg BD for 3 weeks,
CrCl ≥30 mL/min: treatment of 150mg BD Following
10mg BD for 7 days, treatment of 30mg daily (B.W.≤60kg) then 20mg daily
Treatment of a parenteral
anticoagulant CrCl 30-50 mL/min: a parenteral
then 5mg BD
for ≥5 days anticoagulant CrCl 15-50 mL/min or CrCl 15-49 mL/min:
DVT and PE 150mg BD or 110mg BD for ≥5 days concurrent P-gp inhibitors∆: 15mg BD for 3 weeks,
(based on individual assessment^) @
CrCl 15-29 mL/min: Use with Caution 30mg daily then 20mg daily or 15mg daily
CrCl <15 mL/min: Not Recommended CrCl <30 mL/min: Contraindicated CrCl <15 mL/min: Not Recommended CrCl <15 mL/min: Not Recommended
CrCl ≥50 mL/min: CrCl >50 mL/min: CrCl ≥50 mL/min:
150mg BD 60mg daily (B.W.>60kg) 10mg daily or
CrCl ≥30 mL/min: 30mg daily (B.W.≤60kg) 20mg daily (high risk patient)
Following 2.5mg BD Following
Prevention of completion CrCl 30-50 mL/min: completion CrCl 15-49 mL/min:
of 6 months 150mg BD or 110mg BD of ≥6 months Original dose 20mg daily:
Recurrent DVT of DVT/PE (based on individual assessment^) CrCl 15-50 mL/min or of DVT/PE 20mg daily or
Treatment concurrent P-gp inhibitors∆: Treatment
15mg daily@
and PE CrCl 15-29 mL/min: 30mg daily
Use with Caution CrCl <30 mL/min: Contraindicated Original dose 10mg daily:
10mg daily
CrCl <15 mL/min: Not Recommended CrCl <15 mL/min: Not Recommended CrCl <15 mL/min: Not Recommended
CrCl ≥50 mL/min:
Prevention of 110mg once (within 4 hours of completed
CrCl ≥30 mL/min: surgery) then 220mg daily CrCl ≥30 mL/min:
VTE in Elective 2.5mg BD Hip: 28-35 days; Knee: 10 days 10mg daily
(initial dose 12-24 hours after surgery) CrCl 30-50, Age ≥75, or concurrent P-gp inhibitors*: (initial dose 6-10 hours after surgery)
Hip or Knee Hip: 32-38 days; Knee: 10-14 days 75mg once (within 4 hours of completed Hip: 5 weeks; Knee: 2 weeks
#
Replacement surgery) then 150mg daily
Hip: 28-35 days; Knee: 10 days
Surgery CrCl 15-29 mL/min: Use with Caution
CrCl <30 mL/min: Contraindicated CrCl <30 mL/min:
CrCl <15 mL/min: Not Recommended Not Recommended
Dabigatran Edoxaban
∆
Rivaroxaban
@
* Mild to moderate P-gp inhibitors including amiodarone, quinidine, or verapamil Specified P-gp inhibitors include ciclosporin, 15mg daily if the patient’s assessed risk for bleeding
^Age ≥80 or concurrent verapamil: 110mg BD dronedarone, erythromycin, ketoconazole outweighs the risk for recurrent DVT or PE
Age 75-80, CrCl 30-50, Patients with gastritis, oesophagitis or gastroesophgeal reflux, or at increased risk of (No dose reduction required for concurrent
Last Updated in Nov 2019 by PMH Pharmacy #
bleeding: Select 150mg BD or 110mg BD based on individual risk assessment amiodarone, quinidine, or verapamil)
Ref: Drug Insert, unless otherwise stated CrCl 30-50 and concomitant verapamil: 75mg daily should be considered