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Renal Function Estimates and Dosing of Direct Oral Anticoagulants in Stroke Patients with Atrial Fibrillation: An
Yen-Ting Chen1, Huey-Juan Lin1
1Department of Neurology, Chi-Mei Medical Center, Tainan, Taiwan.
Insights
Estimated glomerular filtration rate (eGFR) may misclassify renal function in atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs), potentially leading to incorrect dosing. Clinicians’ cautious prescribing practices may mitigate some risks in stroke patients.
Area of Science:
- Cardiology
- Nephrology
- Pharmacology
Background:
- Accurate assessment of renal function is crucial for appropriate direct oral anticoagulant (DOAC) dosing.
- Discrepancies between estimated glomerular filtration rate (eGFR) and creatinine clearance (CrCl) may impact DOAC dosing in patients with atrial fibrillation (AF).
Purpose of the Study:
- To investigate the impact of using eGFR versus CrCl on DOAC dosing appropriateness in patients with AF following a stroke.
- To evaluate the real-world consequences of renal function estimation discrepancies on DOAC therapy.
Main Methods:
- Retrospective analysis of a hospital-based stroke registry (2014-2017).
- Inclusion of consecutive patients hospitalized for acute stroke with AF, initiated on DOACs within 90 days.
- Comparison of dosing appropriateness based on eGFR and CrCl, with verification of effectiveness and safety outcomes via chart review.
Main Results:
- Substitution of eGFR for CrCl led to significant misclassification in 55% of patients with CrCl < 50 mL/min and 89% with CrCl < 30 mL/min, risking overdosing.
- Misclassification could result in underdosing for 6% of patients with CrCl ≥50 mL/min.
- Actual DOAC use showed reduced overdosing (10% to 4% for dabigatran, 2% to 1% for rivaroxaban) but increased underdosing (17% to 26% for rivaroxaban).
- Over a median follow-up of 17 months, the event rate for effectiveness was 6.9% per year and for safety (major bleeding) was 9.6% per year.
Conclusions:
- While using eGFR instead of CrCl for DOAC dosing in AF patients presents risks of overdosing, this may be counteracted by clinical practice favoring lower doses.
- The study highlights the importance of precise renal function assessment for optimizing DOAC therapy in stroke patients with AF.
Purpose:
Appropriate dosing of direct oral anticoagulants (DOACs) requires consideration of renal function. Discordance between commonly used estimated glomerular filtration rate (eGFR) and creatinine clearance (CrCl) might affect the dosing appropriateness in stroke patients with atrial fibrillation (AF). We aimed to explore the effect of renal function estimates on the dosing patterns in a real-world setting.
Methods:
Using a hospital-based stroke registry, we identified consecutive patients between 2014 and 2017 who were hospitalized for acute stroke, had AF, and started DOACs within 90 days after stroke. We compared the difference between eGFR and CrCl in assessing appropriateness of dosage. Effectiveness and safety outcomes were verified by chart review, and event rates were presented as per 100 person-years.
Results:
Of the156 patients with mean age 74±11 years, 72 (46%) were prescribed dabigatran and 84 (54%) rivaroxaban. Substituting eGFR for CrCl would have 55% (37/67) of patients with CrCl less than 50 mL/min and 89% (8/9) of patients with CrCl less than 30 mL/min not correctly classified, and potentially lead to overdosing. The misclassification would cause underdosing in 6% (5/89) of patients with CrCl ≥50 mL/min and 1% (1/147) of patients with CrCl ≥30 mL/min. In reality, the substitution resulted in reduction of overdosing from 10% to 4% for dabigatran and from 2% to 1% for rivaroxaban; underdosing increased from 17% to 26% for rivaroxaban. After median follow-up of 17 months, 33 patients developed outcomes including 21 major bleedings. The event rate was 6.9% per year (95% CI, 4.1%-11.4%) for effectiveness, and 9.6% per year (95% CI, 6.3%-14.8%) for safety.
Conclusion:
Although substituting eGFR for CrCl carries potential risks of DOAC overdosing in patients with AF, the effect might be offset by clinicians' predilection for lower dosage in this stroke cohort.
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