From the Guidelines
Direct oral anticoagulants (DOACs) are contraindicated in patients with stage IV chronic kidney disease, active or clinically significant liver disease, and those taking strong dual inhibitors/inducers of CYP3A4 and P-glycoprotein. The use of DOACs is also contraindicated in patients with active bleeding or high bleeding risk conditions, as well as those with a history of hypersensitivity reactions to these medications 1. Additionally, DOACs should be avoided in patients with mechanical heart valves, moderate to severe mitral stenosis, or antiphospholipid syndrome.
Specific Contraindications
- Stage IV chronic kidney disease: apixaban is contraindicated when creatinine clearance is below 25 mL/min, while rivaroxaban, edoxaban, and dabigatran should be avoided when clearance falls below 30 mL/min 1
- Active or clinically significant liver disease: apixaban or edoxaban should be avoided when ALT/AST is greater than 2 x ULN or total bilirubin is greater than 1.5 x ULN 1
- Strong dual inhibitors/inducers of CYP3A4 and P-glycoprotein: see prescribing information for rivaroxaban and dabigatran 1
Relative Contraindications
- Patients with compromised renal or liver function should use DOACs with caution 1
- Patients with urinary or gastrointestinal tract lesions, pathology, or instrumentation should use DOACs with caution due to increased bleeding risk 1
- Patients receiving nephrotoxic or hepatotoxic chemotherapy should be monitored closely with laboratory testing 1 According to the most recent guidelines, the use of DOACs should be avoided in patients with active cancer involving the gastrointestinal or genitourinary tracts due to increased bleeding risk in these tissues 1. Furthermore, DOACs are generally not recommended for patients with high-risk invasive procedures, severe thrombocytopenia, or those with a history of hypersensitivity reactions to these medications 1.
From the FDA Drug Label
The use of dabigatran etexilate capsules are contraindicated in all patients with mechanical prosthetic valves Direct-acting oral anticoagulants (DOACs), including dabigatran etexilate capsules, are not recommended for use in patients with triple-positive antiphospholipid syndrome (APS)
The contraindications for DOACs, such as dabigatran, are:
- Patients with mechanical prosthetic valves
- Patients with triple-positive antiphospholipid syndrome (APS), as they have an increased risk of thrombosis 2
From the Research
Contraindications for DOACs
The following circumstances may contraindicate the use of Direct Oral Anticoagulants (DOACs):
- Severe renal impairment: DOACs are not recommended for patients with end-stage renal disease (ESRD) with or without dialysis 3
- Kidney transplant patients under immunosuppression with calcineurin inhibitors: Conventional therapy with vitamin K antagonists (VKAs) is the only option for these patients 3
- Patients with rare renal disease and hypercoagulable state: DOACs may be considered in some cases, but careful monitoring of renal function is essential 3
- Acute renal failure: Patients at risk for acute renal failure, such as the elderly, diabetics, and those with preexisting kidney disease, require careful monitoring of renal function before initiation and after start of DOAC therapy 3
Renal Impairment Considerations
When using DOACs in patients with renal impairment:
- Dose adjustments are required for patients with moderate to severe renal impairment 4
- Accurate estimation of renal function is crucial for DOAC dosing 5
- Inappropriately dosed DOACs may increase the risk of ischemic events or bleeding 4
- Patients with chronic kidney disease (CKD) have a high burden of cardiovascular risk and are more likely to develop atrial fibrillation (AF) than patients without CKD 3