Renal dosing of non–vitamin K antagonist oral anticoagulants in atrial fibrillation is important in preventing thrombotic and bleeding complications


Clinical question: Does renal underdosing and overdosing of non–vitamin K antagonist oral anticoagulants (NOACs) impact the risk of thrombotic and bleeding complications?

Background: All of the NOACs have at least partial renal clearance, but compliance with Food and Drug Administration–labeled renal dosing recommendations is inconsistent. This study examines the risk of adverse thrombotic and bleeding events in patients with improper anticoagulant dosing.

Study design: Retrospective cohort study.

Setting: United States (OptumLabs data warehouse, a database of over 100 million patients hospitalized in the United States in the last 20 years).

Synopsis: With use of data from the OptumLabs data warehouse of privately insured and Medicare Advantage enrollees, 14,865 patients with nonvalvular atrial fibrillation who were started on NOACs (apixaban, dabigatran, or rivaroxaban) were identified. Creatinine values within the year before treatment were used to calculate an estimated glomerular filtration rate (eGFR).

Of patients qualifying for renal dose reduction, 43% received the standard dosing (overdose). Of patients not qualifying for renal dose reduction, 13% received a reduced dose (underdose). The overdosed group had a higher rate of bleeding events, compared with controls (hazard ratio, 2.19; 95% CI, 1.07-4.46). The underdosed group had a higher rate of stroke (HR, 4.87; 95% CI, 1.30-18.26).

Bottom line: Excessive dosing of NOACs in patients with renal insufficiency is common and is associated with bleeding.Citation: Yao X, Shah ND, Sangaralingham LR, Gersh BJ, and Noseworthy PA. Non–vitamin K antagonist oral anticoagulant dosing in patients with atrial fibrillation and renal dysfunction. JACC. 2017;69(23):2779-90.

Dr. Portnoy is hospitalist and instructor of medicine, Icahn School of Medicine of the Mount Sinai Health System.

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