Renal Function Assessment and Direct-Acting Oral Anticoagulants Dosing: Are We Entering a New Age?

Cardiovascular Quality and Outcomes, Rohla et al 1 raise concerns regarding the current practice of basing renal dosing adjustments for direct-acting oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) on estimated creatinine clearance (CrCl). 1 Using registry data for patients with AF, they estimated CrCl using the Cockcroft-Gault (CG) formula and glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas; they compared thromboembolic and bleeding complications between patients with dissimilar renal dosing indications using the 3 formulas based on prescribing information in Europe. Nearly 40% of patients would have required dosage adjustment using either the Modification of Diet in Renal Disease or CKD-EPI formulas instead of CG. Importantly, thromboembolic events were 5-fold higher in patients whose DOAC dose would have been adjusted based on reclassification using the CKD-EPI formula compared with the CG formula (4.1% versus 0.8%, P=0.01). Major bleeding events were also numerically greater in patients who were reclassified using the CKD-EPI formula (5.7% versus 2.7%, P=0.09), but the difference was not statistically significant.