Direct Oral Anticoagulant Dosing in Patients With Atrial Fibrillation

Figures

• 

  Central Illustration. Scenarios of DOAC Dosing This figure provides an overview of the direct oral anticoagulant (DOAC) prescribing scenarios. The green boxes represent the scenarios that are recommended, in which patients meet the criteria for the higher dose or they meet the criteria for the labeled lower dose based on patients’ characteristics. The red/orange boxes are scenarios that physicians should avoid. The gray area box is for patients who are outside the eligibility criteria of pivotal randomized controlled trials. The choice of the DOAC dose needs to be carefully considered based on limited evidence. AF = atrial fibrillation; BID = twice daily; OD = once daily.

• 

  Figure 1. Dose Reduction Criteria for Treatment With Direct Oral Anticoagulants This figure represents the summarized opinion for dose reduction criteria for direct oral anticoagulant treatment. Avoid unnecessary complications by following regulatory labeling. Gray area patients, defined as patients outside the eligibility criteria of pivotal randomized controlled trials, need to be managed very carefully.

• 

  Figure 2. Nonrecommended Low Dosing of Direct Oral Anticoagulants This figure represents the summarized opinion for dosing patients with a nonrecommended low dose. The 2 common scenarios are described. Scenario 1 represents the gray area patient in which no clear evidence is available. Scenario 2 represents the patients in which higher dosing needs to be prescribed and emphasizes the importance to physicians.

• 

  Figure 3. Practical Considerations for Dosing in a Real-World Setting (e.g., Edoxaban) This figure utilizes edoxaban as an example of dose adjustment in a real-world setting and considers how the dose may be adjusted (up- or downtitrated) according to the patients’ characteristics as they change over time. For example, 60 mg/d is offered as a starting point to all patients unless they meet the criteria for dose reduction. For the elderly high-risk patient, 15 mg/d can be prescribed. When patient characteristics change (eg, the creatinine clearance improves and the risk of bleeding reduces), physicians should always consider to step up the lower dose to the higher dose. ELDERCARE-AF = Edoxaban Low-Dose for Elder Care-Atrial Fibrillation Patients; ENGAGE-AF TIMI 48 = Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation Thrombolysis In Myocardial Infarction 48.

• 

  Figure 4. Dose Adjustment of Direct Oral Anticoagulants for Gray-Area Patients This figure represents the summarized opinion for dose adjustment for all direct oral anticoagulants. CrCl = creatinine clearance.

• 

  Figure 5. Future Perspectives on Dosing of Direct Oral Anticoagulants in Asia This figure represents the summarized opinion for future considerations of direct oral anticoagulant dosing for Asian patients. TDM = therapeutic drug monitoring.