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DOAC Dosing During AKI — ESENeph MCQ

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ModerateAcute Kidney InjuryDOAC Dosing During AKIESENeph

A 60-year-old man with CKD G3b and atrial fibrillation on Apixaban develops AKI from gastroenteritis. His eGFR falls from 38 to 18 mL/min/1.73m2. What should happen to his anticoagulation?

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Correct answer: E — Review Apixaban dosing – AKI reduces renal clearance of DOACs, potentially increasing drug levels and bleeding risk; consider temporary dose adjustment or withholding during acute illness with close monitoring

AKI reduces renal clearance of all DOACs (though Apixaban has the lowest renal dependence at ~27%). During significant AKI, drug accumulation increases bleeding risk. NICE and BNF recommend reviewing DOAC dosing during acute illness with eGFR changes. Options include temporary dose reduction, withholding during the acute phase with thromboprophylaxis assessment, or bridging with dose-adjusted LMWH. The decision depends on bleeding versus thrombotic risk. Once AKI resolves, the usual dose can be resumed.

Reference: BNF 2024 – Apixaban; NICE NG196 – AF; KDIGO 2024 – CKD