Available anticoagulants and considerations for use in management of VTE in CLD
| Characteristic . | VKA . | LMWH . | Dabigatran . | Apixaban . | Edoxaban . | Rivaroxaban . |
|---|---|---|---|---|---|---|
| Dosing | Variable od, based on INR | Weight based, once or twice daily | Twice daily | Twice daily | Once daily | Twice daily for 3 weeks, then once daily |
| Initiation | Overlap with LMWH until INR >2. Use alternate agent if baseline INR increased | As above | ≥5 days LMWH, then switch | 10 mg twice daily for 7 days | 5 days LMWH, then switch | 15 mg twice daily for 3 weeks |
| Standard dose | Variable as above | As above | 150 mg bd | 5 mg twice daily from day 8 | 60 mg od | 20 mg once daily from day 22 |
| Dose reduction | NA | CrCl 15-30 mL, reduce dose | 110 mg bd for age ≥80 years or concomitant verapamil and consider for other high-risk groups | Consider dose reduction to 2.5 mg bd from 6 months | 30 mg od for CrCl <50 mL/min or weight <60 kg | Consider dose reduction to 10 mg from 6 months |
| Drug monitoring | Y | N | N | N | N | N |
| Hepatobiliary/intestinal elimination | Predominant | Minimal | 20% | 73% | 50% | 34% |
| CLD | ||||||
| CPC A | Y | Y | Y | Y | Caution, avoid if ALT/AST <2 × ULN and bilirubin <1.5 × ULN | Y |
| CPC B | Y | Y | Limited experience, no change in exposure in n = 12 | Y in absence of coagulopathy | N | |
| CPC C | Y | Y | N | N | N | N |
| CKD | ||||||
| CrCl, 15-30 mL/min | Y | ↓Dose | Do not use | Limited experience | Limited experience | Limited experience |
| <15 mL/min | Y | Avoid | Do not use | Do not use | Do not use | Do not use |
| Characteristic . | VKA . | LMWH . | Dabigatran . | Apixaban . | Edoxaban . | Rivaroxaban . |
|---|---|---|---|---|---|---|
| Dosing | Variable od, based on INR | Weight based, once or twice daily | Twice daily | Twice daily | Once daily | Twice daily for 3 weeks, then once daily |
| Initiation | Overlap with LMWH until INR >2. Use alternate agent if baseline INR increased | As above | ≥5 days LMWH, then switch | 10 mg twice daily for 7 days | 5 days LMWH, then switch | 15 mg twice daily for 3 weeks |
| Standard dose | Variable as above | As above | 150 mg bd | 5 mg twice daily from day 8 | 60 mg od | 20 mg once daily from day 22 |
| Dose reduction | NA | CrCl 15-30 mL, reduce dose | 110 mg bd for age ≥80 years or concomitant verapamil and consider for other high-risk groups | Consider dose reduction to 2.5 mg bd from 6 months | 30 mg od for CrCl <50 mL/min or weight <60 kg | Consider dose reduction to 10 mg from 6 months |
| Drug monitoring | Y | N | N | N | N | N |
| Hepatobiliary/intestinal elimination | Predominant | Minimal | 20% | 73% | 50% | 34% |
| CLD | ||||||
| CPC A | Y | Y | Y | Y | Caution, avoid if ALT/AST <2 × ULN and bilirubin <1.5 × ULN | Y |
| CPC B | Y | Y | Limited experience, no change in exposure in n = 12 | Y in absence of coagulopathy | N | |
| CPC C | Y | Y | N | N | N | N |
| CKD | ||||||
| CrCl, 15-30 mL/min | Y | ↓Dose | Do not use | Limited experience | Limited experience | Limited experience |
| <15 mL/min | Y | Avoid | Do not use | Do not use | Do not use | Do not use |
Modified from Northup et al20 with permission from Wiley.
ALT, alanine aminotransferase; AST, aspartate aminotransferase; bd, twice daily; CKD, chronic kidney disease; CPC, Child-Pugh classification; CrCl, creatinine clearance; N, no; NA, not applicable; od, once daily; ULN, upper limit of normal; Y, yes.