Hospital Care Plan

Renally impaired patient: Wants to switch from warfarin to DOAC. Which would you recommend?

Recommend apixaban as best choice. Least renal clearance in comparison to other DOACs. Best option in CKD.

A renally impaired patient with CrCl less than 15mL/min, what anticoagulation method would be preferred?

Avoid DOAC and initiate warfarin, warfarin is not renally cleared and always for increased monitoring.

What other DOACs would be suitable in renal impairment?

Edooxaban can be used, but apixaban remain best option

What DOAC would we avoid in renal impairement?

Dabigatran contraindicated – CrCl<30ml/min

When may we want to avoid the use of Rivaroxaban?

Insufficient dietary intake, if patient is elderly and does not have much apepetite etc. Rivaroxaban required more than 500 calories for sufficient absorption so a insufficient dietary intake can reduce its absorption and increase risk of clot.

When would we need to reduce the dose of apixaban?

Reduce dose with at least two of the following:

• patient under 60kg

• patient over 80 years

• serum creatinine 133 micromol/l and over

OR

• If CrCL 15-29 mL/min reduce dose to 2.5mg BD regardless of other factors

Patient is currently on warfarin wanting to switch to DOAC. The doctor asks your advice on drug choice, dose and how to switch from warfarin. How do you
respond? This is for a patient with CrCL = 24

• Apixaban 2.5mg BD

• Apixaban is preferred because it is least renally cleared DOAC

• Dose reduction required as CrCL 15-29ml/min as per BNF.

• To switch from warfarin to DOAC - Stop warfarin when INR is less than 2 and then immediately start Apixaban

How would you switch from warfarin to edoxoban?

Stop warfarin and start edoxaban when INR is less than or equal to 2.5

How would you switch from DOAC to warfarin

start warfarin + continue DOAC short-term + monitor INR closely + stop DOAC when INR therapeutic

When counselling Mrs Logan on her new DOAC prescription and what to do in the event of a missed
dose, Mrs Logan tells you she isn’t too worried about that – she used to miss the odd dose of warfarin
now and again and it didn’t make a difference to her INR. How do you respond?

Explore further with Mrs Logan – forgetting doses vs. intentional non-adherence
• Educate that DOACs have a very short duration of action compared to warfarin
• Missing a single dose can result in loss of anticoagulation and increased risk of clotting

DOACs are fast acting and have a shorter half life which means that missing a dose will have a greater risk of clot forming. Whereas warfarin has a longer duration of action/ half life and a slower onset so takes about 3-5 after inition to show effect. Missing a dose of warfarin would not dramatically affect INR as drug levels would not fall instantly. this is not the case for DOACs where missing one dose will increase risk of clot due to shorter acting drug.