Table 2.

Chronic kidney disease categories lacking randomized clinical trial data on the utility of anticoagulation^4,63,64

eCrCl (mL/min)a	Warfarin	Apixabanb	Dabigatran	Edoxaban	Rivaroxaban
15–30	Adjusted dose for INR 2–3 could be considered	2.5 mg PO b.i.d. could be considered	Unknown (75 mg PO b.i.d.)c,d	30 mg QDe could be considered	15 mg QD could be considered
<15 not on dialysis	Equipoise based on observational data and meta-analysis	Unknown (2.5 mg PO b.i.d.)c	Not recommended	Not recommended	Unknown (15 mg QD)c
<15 on dialysis	Equipoise based on observational data and meta-analysis	Unknown (2.5 mg PO b.i.d.)c	Not recommended	Not recommended	Unknown (15 mg QD)c

INR, international normalized ratio. Dosing of direct oral anticoagulants (DOACs) based solely on limited pharmacokinetic and pharmacodynamic data (no randomized efficacy or safety data exist).

^aCockcroft-Gault estimated creatinine clearance.

^bApixaban dose needs modification to 2.5mg b.i.d. if patient has any two of the following: serum creatinine ≥1.5mg/dL, age ≥80years, or body weight ≤60kg.

^cDOAC doses listed in parenthesis are doses that do not currently have any clinical safety or efficacy data. The doses of DOACs apixaban 5mg b.i.d.^b, rivaroxaban 15mg QD and dabigatran 75mg b.i.d. are included in the United States Food and Drug Administration approved labelling based on limited dose pharmacokinetic and pharmacodynamics data with no clinical safety data. We suggest consideration of the lower dose of apixaban 2.5mg PO b.i.d. in CKD G5/G5D to reduce bleeding risk until clinical safety data are available.

^dDabigatran 75mg available only in the USA.

^eThe dose was halved if any of the following: estimated CrCl of 30–50mL/min, body weight of ≤60kg, or concomitant use of verapamil or quinidine (potent P-glycoprotein inhibitors).