Factors that may influence choice of indefinite anticoagulant regimen
| Factor . | Preferred anticoagulant . | Qualifying remarks . |
|---|---|---|
| Cancer | Edoxaban, rivaroxaban, apixaban | Appears to cause more bleeding that LMWH in patients with gastrointestinal lesions. Must be able to take oral therapy. |
| Higher bleeding and lower recurrence risk | Low-dose rivaroxaban or apixaban | Lower-dose regimen assumed to have a somewhat lower risk of bleeding and higher risk for recurrence. |
| When cost is a barrier, we do not prevent patients from splitting tablets. | ||
| Once daily oral therapy preferred | Rivaroxaban; edoxaban; warfarin | |
| Strong CYP3A4 inhibitor or inducer | Edoxaban, warfarin, LMWH | |
| Liver disease and coagulopathy | LMWH | DOACs contraindicated if INR raised due to liver disease; warfarin difficult to control and INR may not reflect antithrombotic effect. |
| Creatinine clearance < 15 ml/min | Warfarin | DOACs and LMWH contraindicated with severe renal impairment. Dosing of DOACs with impairment differ with the DOAC and among jurisdictions.* Use of DOACs with renal impairment may expand in the future. |
| Coronary artery disease | Warfarin, rivaroxaban, apixaban, edoxaban | Coronary artery events appear to occur more often with dabigatran than with warfarin. This has not been noted with the other DOACs, and they have demonstrated efficacy for coronary artery disease. |
| Dyspepsia or history of gastrointestinal bleeding | Warfarin, apixaban | Dabigatran increased dyspepsia. Dabigatran, rivaroxaban and edoxaban may be associated with more gastrointestinal bleeding than warfarin. |
| Poor compliance | Warfarin | INR monitoring can help to detect problems. However, some patients may be more compliant with a DOAC because it is less complex. |
| Higher risk of bleeding | Apixaban | Based on indirect comparisons across randomized trials and findings of observational studies |
| APA positive | Warfarin | Small study suggesting that warfarin is superior to rivaroxaban for prevention of arterial thrombosis in patients with high-risk APAs.42,43 |
| Cost, coverage, licensing | Varies among regions and with individual circumstances |
| Factor . | Preferred anticoagulant . | Qualifying remarks . |
|---|---|---|
| Cancer | Edoxaban, rivaroxaban, apixaban | Appears to cause more bleeding that LMWH in patients with gastrointestinal lesions. Must be able to take oral therapy. |
| Higher bleeding and lower recurrence risk | Low-dose rivaroxaban or apixaban | Lower-dose regimen assumed to have a somewhat lower risk of bleeding and higher risk for recurrence. |
| When cost is a barrier, we do not prevent patients from splitting tablets. | ||
| Once daily oral therapy preferred | Rivaroxaban; edoxaban; warfarin | |
| Strong CYP3A4 inhibitor or inducer | Edoxaban, warfarin, LMWH | |
| Liver disease and coagulopathy | LMWH | DOACs contraindicated if INR raised due to liver disease; warfarin difficult to control and INR may not reflect antithrombotic effect. |
| Creatinine clearance < 15 ml/min | Warfarin | DOACs and LMWH contraindicated with severe renal impairment. Dosing of DOACs with impairment differ with the DOAC and among jurisdictions.* Use of DOACs with renal impairment may expand in the future. |
| Coronary artery disease | Warfarin, rivaroxaban, apixaban, edoxaban | Coronary artery events appear to occur more often with dabigatran than with warfarin. This has not been noted with the other DOACs, and they have demonstrated efficacy for coronary artery disease. |
| Dyspepsia or history of gastrointestinal bleeding | Warfarin, apixaban | Dabigatran increased dyspepsia. Dabigatran, rivaroxaban and edoxaban may be associated with more gastrointestinal bleeding than warfarin. |
| Poor compliance | Warfarin | INR monitoring can help to detect problems. However, some patients may be more compliant with a DOAC because it is less complex. |
| Higher risk of bleeding | Apixaban | Based on indirect comparisons across randomized trials and findings of observational studies |
| APA positive | Warfarin | Small study suggesting that warfarin is superior to rivaroxaban for prevention of arterial thrombosis in patients with high-risk APAs.42,43 |
| Cost, coverage, licensing | Varies among regions and with individual circumstances |
Approved dosing for long-term treatment of VTE according to renal impairment (CrCl in milliliters per minute generally estimated using the Cockcroft-Gault method).
Dabigatran: creatinine clearance (CrCl) ≥30, 150 mg BID in the United States. In Canada and the European Union, with CrCl ≥ 50 and aged either >80 years or 75 to 79 years with a risk factor for bleeding, 110 mg BID. In Canada and the European Union, with CrCl 30 to 49, 110 mg BID. CrCl <30, not approved in the United States, Canada, or the European Union.
Rivaroxaban: CrCl ≥ 30, 20 mg (or 10 mg) OD after 6 months of 20 mg OD in the United States, Canada, and the European Union. CrCl 15 to 29, 20 mg (or 10 mg) OD after 6 months of 20 mg OD in Canada or the European Union and not approved in the United States. CrCl <15, not approved in the United States, Canada, or the European Union.
Apixaban: CrCl ≥15, 2.5 mg BID after 6 months of 5 mg BID in the United States, Canada, or the European Union. CrCl <15, 2.5 mg BID after 6 months of 5 mg BID in the United States and not approved in Canada or the European Union.
Edoxaban: CrCl >50, 60 mg OD (30 mg OD if ≤60 kg or concomitant strong P-gp inhibitors except amiodarone or verapamil) in Canada or the European Union (in the United States, same dosing as for acute VTE treatment, but edoxaban does not have specific approval for extended treatment). CrCl 30 to 50, 30 mg OD in Canada or the European Union (in the United States, same dosing as for acute VTE treatment, but edoxaban does not have specific approval for extended treatment). CrCl 15 to 29, 30 mg OD in the European Union (in the United States, same dosing as for acute VTE treatment, but edoxaban does not have specific approval for extended treatment) and not approved in Canada. CrCl <15, not approved in the United States, Canada, or the European Union.