Table 3.
| eCrCl (ml/min) | Warfarin | DOACs | |||
|---|---|---|---|---|---|
| Dabigatran | Apixaban | Edoxaban | Rivaroxaban | ||
| >95 | Adjusted dose for INR 2–3 | 150 mg b.i.d. | 5 mg b.i.d.a | 60 mg QDb,c | 20 mg QD |
| 51–95 | Adjusted dose for INR 2–3 | 150 mg b.i.d. | 5 mg b.i.d.a | 60 mg QDc | 20 mg QD |
| 31–50 (25–50)d | Adjusted dose for INR 2–3 | 150 mg b.i.d. or 110 mg b.i.d.b | 5 mg b.i.d.a | 30 mg QDc | 15 mg QD |
| 15–30 | Adjusted dose for INR 2–3 (consider) | 75 mg po b.i.d.e | 2.5 mg b.i.d. (consider) | 30 mg QDc (consider) | 15 mg QD (consider) |
| <15 (not on dialysis) | Equipoise on the basis of observational data and meta-analysis | Not recommended | 2.5 mg po b.i.d.e | Not recommended | 15 mg QDe |
| <15 (on dialysis) | Equipoise on the basis of observational data and meta-analysis | Not recommended | 2.5 mg po b.i.d.e | Not recommended | 15 mg QDe |
eCrCl, estimated creatinine clearance; DOACs, direct oral anticoagulants; INR, international normalized ratio; b.i.d., twice daily; QD, once daily; po, per os.
2.5 mg twice daily if two of the three criteria are met: creatinine ≥1.5 mg/dl, body weight ≤60 kg, aged 80 years or older.
Application of this dosage in patients with CKD has not been approved by Food and Drug Administration.
The dose is halved if any of the three criteria are met: estimated creatinine clearance of 30 approximately 50 ml/min, body weight ≤60 kg, concomitant use of verapamil or quinidine.
Estimated creatinine clearance values referenced for dose adjustment of apixaban.
This application is recommended by Kidney Disease Improving Global Outcomes but lacks clinical safety or efficacy data.