Are direct oral anticoagulants safe and effective in patients with non-valvular atrial fibrillation or venous thromboembolism and co-existing moderate-severe renal impairment?
Accurate estimation of renal function is crucial for appropriate DOAC dosing in patients with chronic kidney disease to prevent avoidable thromboembolic and bleeding events.
Increasing use of direct oral anticoagulants (DOACs) has made management of non-valvular atrial fibrillation and venous thromboembolism easier in most patients. But the presence of co-existing renal impairment could render the use of DOACs problematic because all of these drugs have varying degrees of renal excretion. In this paper we address misconceptions about the safety and efficacy of DOACs in moderate-severe renal impairment by presenting a summary of the literature from phase III trials and real-world studies. It also addresses the important consideration of correct estimate of renal function for DOAC dosing. It is hoped that the review will serve as a valuable resource for clinicians involved in anticoagulation decision-making in patients with renal impairment to guide the choice of most suitable agent. Accurate dosing is of particular relevance as registry data suggests it is done inconsistently and may be resulting in avoidable thromboembolic and bleeding events.
Parker et al. (2018) studied this question.