The Need for Randomized Trials to Define the Optimal Dose of Anticoagulants for Atrial Fibrillation in Chronic Kidney Disease

ptimal drug dosing should be the dose shown to be safe and effective in randomized trials.For patients with atrial fibrillation (AF) who are similar to patients included in the ARISTOTLE trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation), the apixaban dose should be 5 mg twice daily, or 2.5 mg in those with at least 2 dosereduction criteria (age ≥80 years, weight ≤60 kg, and creatinine level ≥1.5 mg/dL).With respect to chronic kidney disease (CKD), we can be confident in the standard dosing for estimated creatinine clearance (CrCl) down to 25 mL/min, or into the stage 4 CKD population, as these patients were included in ARISTOTLE.European Medicines Agency labeling differs from that of the Food and Drug Administration and recommends 1 dose-reduction criterion (if CrCl is 15 to 29 mL/min).