What direct oral anticoagulant (DOAC) to initiate in a patient with pulmonary embolism (PE) and impaired renal function, specifically a glomerular filtration rate (GFR) of 30, and what is the recommended dose?

From the Guidelines

For a patient with pulmonary embolism (PE) and a GFR of 30 mL/min, rivaroxaban would be the preferred direct oral anticoagulant (DOAC) at a reduced dose of 15 mg once daily. This recommendation is based on the most recent guidelines from the European Heart Journal 1, which provide dosing recommendations for DOACs in patients with renal impairment. The guidelines recommend a reduced dose of rivaroxaban to 15 mg once daily for patients with a creatinine clearance of 15-49 mL/min. Key considerations for this patient include:

• Regular monitoring of renal function during treatment
• Education about bleeding risks and signs
• Potential need to switch to an alternative anticoagulant if renal function worsens. Rivaroxaban is preferred over other DOACs due to its relatively lower renal clearance and established safety profile in patients with reduced renal function 1. In contrast, apixaban, dabigatran, and edoxaban may require more significant dose adjustments or are contraindicated at this level of renal impairment 1. Additionally, the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism support the use of DOACs for anticoagulation in patients with PE 1.

From the Research

Direct Oral Anticoagulants (DOACs) for Pulmonary Embolism (PE) with Renal Impairment

• Patients with PE and renal impairment are at increased risk of recurrent thrombosis and bleeding 2
• DOACs are the first-choice treatment for acute VTE in eligible patients, but their use can be complicated in patients with renal impairment due to renal excretion 2

Choice of DOAC for PE with GFR of 30

• Apixaban is a possible option for patients with severe renal impairment, including those with a GFR of 30 3
• The safety and efficacy of apixaban in patients with end-stage renal disease (ESRD) have been supported by several studies 3

Dosing of DOAC for PE with GFR of 30

• The dosing of apixaban in patients with severe renal impairment, including those with a GFR of 30, should be carefully considered, but specific dosing recommendations are not provided in the available evidence 3
• Reduced doses of DOACs, such as apixaban and rivaroxaban, may be considered for patients requiring extended duration of treatment 4

Considerations for Patients with PE and Renal Impairment

• Renal function should be cautiously considered during the diagnostic workup and treatment of PE, as renal dysfunction can predict short- and long-term outcomes 5
• The risk of bleeding and thromboembolic events should be carefully balanced when selecting a DOAC for patients with PE and renal impairment 6, 3