Anticoagulants: dose adjustments for newer anticoagulants

Monitor renal function:

  • before starting treatment[1]
  • at least annually in older people (≥ 75 years) or people with CrCl < 50 mL/min; more frequent monitoring (e.g. every 3–6 months) may be warranted[2,3]
  • when a decline in renal function is suspected (e.g. low blood volume, dehydration or when medicines that affect renal function are given concomitantly).[1]

Table 1: Dabigatran[4,5


Stroke prevention in non-valvular AF
Prevention of VTE after hip/knee replacement
Normal adult dose 150 mg twice daily 220 mg once daily
Age > 75 years 110 mg twice daily 220 mg once daily
CrCl 30–50 mL/min or increased risk of bleeding Reduced dose of 110 mg twice daily may be considered 150 mg once daily
CrCl ≤ 29 mL/min Contraindicated
 

Dabigatran capsules should be swallowed whole with a full glass of water. The capsule should not be opened, broken or chewed as this may increase the risk of bleeding.

Dabigatran can be taken with or without food. Taking dabigatran with food may reduce dyspepsia.

Note: The Cockcroft–Gault formula was used in the clinical trials. This method is recommended when assessing patient CrCl (mL/min) before and during dabigatran treatment. For an online CrCl calculator, see the Australian Medicines Handbook online calculator at www.amh.net.au/online/misc/creatinineclearancecalculator.php

Table 2: Rivaroxaban[5,6]


Stroke prevention in non-valvular AF Prevention of VTE after hip/knee replacement DVT treatment and prevention of recurrent DVT and PE
Normal adult dose 20 mg[A] once daily 10 mg[A] once daily 15 mg[A] twice daily for 3 weeks, followed by 20 mg[A] once daily
CrCl 30–49 mL/min 15 mg[A] once daily 10 mg[A] once daily
CrCl 15–29 mL/min Contraindicated 10 mg[A] once daily (Caution - limited data) Contraindicated
CrCl < 15 mL/min or on dialysis Contraindicated
[A] Rivaroxaban 10 mg tablets can be taken with or without food. Rivaroxaban 15 mg and 20 mg tablets should be taken with food for optimal oral bioavailability.

Table 3: Apixaban for stroke prevention in non-valvular AF[5,7]


Stroke prevention in non-valvular AF
Normal adult dose
5 mg twice daily

Patients with at least TWO of the following characteristics:

  • ≥ 80 years
  • Body weight ≤ 60 kg
  • Serum creatinine ≥ 133 micromol/L
2.5 mg twice daily
CrCl < 25 mL/min or on dialysis
Contraindicated[B]

Apixaban tablets can be taken with or without food.

[B] Limited experience in patients with CrCl 15 to < 25 mL/min and no experience in patients with CrCl < 15 mL/min or on dialysis.

Table 4: Apixaban for prevention of VTE after hip/knee replacement[5,7]


Prevention of VTE after hip/knee replacement
Normal adult dose
2.5 mg twice daily
CrCl < 25 mL/min or on dialysis Contraindicated[B]

Apixaban tablets can be taken with or without food.

[B] Limited experience in patients with CrCl 15 to < 25 mL/min and no experience in patients with CrCl < 15 mL/min or on dialysis.

References

  1. Therapeutic Goods Administration Department of Health and Ageing. Dabigatran (Pradaxa) and risk of bleeding: Information for health professionals. 2013. Updated 23 May 2013. (accessed 26 June 2013).
  2. Alberts MJ, Eikelboom JW, Hankey GJ. Antithrombotic therapy for stroke prevention in non-valvular atrial fibrillation. Lancet neurology 2012;11:1066–81.
  3. Heidbuchel H, et al. European Hearth Rhythm Association Practical Guide on the use of the new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace: 2013;15:625-51. doi:10.1093/europace/eut083
  4. Boehringer Ingelheim Pty Limited. Pradaxa (dabigatran etexilate) Product Information. 5 April 2013.
  5. Australian medicines handbook. Adelaide: Australian Medicines Handbook Pty Ltd, 2013.
  6. Bayer Australia Limited. Xarelto (rivaroxaban) Product Information. 27 June 2013.
  7. Bristol-Myers Squibb Australia Pty Ltd. Eliquis (apixaban). 29 April 2013.