What are the dosing considerations for Eliquis (apixaban) vs Xarelto (rivaroxaban) in patients with impaired renal function?

Dosing Considerations for Eliquis vs. Xarelto in Patients with Impaired Renal Function

Apixaban (Eliquis) is preferred over rivaroxaban (Xarelto) for patients with impaired renal function due to its lower renal clearance (27% vs 33%) and more favorable safety profile in patients with declining renal function. 1

Renal Clearance Comparison

• Apixaban (Eliquis):

  • 27% renal clearance 1
  • Less affected by declining renal function
  • Demonstrated increasing safety advantage over warfarin as renal function declines 2

• Rivaroxaban (Xarelto):

  • 33% renal clearance 1
  • More dependent on renal elimination
  • Requires more significant dose adjustment in renal impairment

Specific Dosing Recommendations

Apixaban (Eliquis)

• Normal to Mild Renal Impairment (CrCl >50 mL/min):

  • Standard dose: 5 mg twice daily 3

• Moderate Renal Impairment (CrCl 15-50 mL/min):

  • 5 mg twice daily unless patient meets dose reduction criteria 1
  • Reduce to 2.5 mg twice daily if patient has at least 2 of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 3

• Severe Renal Impairment (CrCl <15 mL/min) or Dialysis:

  • 2.5 mg twice daily 1, 3
  • Apixaban is the only DOAC approved for use in dialysis patients in the US 1

Rivaroxaban (Xarelto)

• Normal Renal Function (CrCl >50 mL/min):

  • 20 mg once daily 3, 4

• Moderate to Severe Renal Impairment (CrCl 15-50 mL/min):

  • 15 mg once daily (25% dose reduction) 1, 3, 4

• End-Stage Renal Disease (CrCl <15 mL/min):

  • Avoid use 1, 4

Clinical Evidence and Safety Considerations

• A study from ARISTOTLE trial demonstrated that apixaban caused less major bleeding than warfarin in patients with CrCl 25-30 mL/min, with even greater reductions in bleeding than in patients with CrCl >30 mL/min 2

• Pharmacokinetic studies show substantial overlap in the range of exposure to apixaban 5 mg twice daily for patients with or without advanced chronic kidney disease, supporting conventional dosing in patients with CrCl 25-30 mL/min 2

• For rivaroxaban, clinical pharmacology studies have demonstrated an increase in systemic exposure with decreasing renal function, with comparable increases in exposure among individuals with moderate or severe renal impairment 5

Monitoring Recommendations

• Regular monitoring of renal function is essential for patients on DOACs:

  • The European Society of Cardiology recommends evaluating renal function every 3-6 months in patients on DOACs 3
  • More frequent monitoring may be needed in patients with unstable renal function

• While routine coagulation monitoring is not required for either drug, patients should be educated about signs and symptoms of bleeding 1

Common Pitfalls and Caveats

1. Incorrect assessment of renal function: Always use the Cockcroft-Gault equation to calculate creatinine clearance for DOAC dosing decisions 1

2. Failure to reassess renal function: Renal function can decline over time, especially in elderly patients, requiring dose adjustments

3. Drug interactions: Both agents have interactions with P-gp and CYP3A4 inhibitors/inducers, which can affect plasma concentrations 4

4. Administration considerations: Rivaroxaban 15-20 mg doses should be taken with food to ensure adequate absorption 3, 4

5. Transitioning between anticoagulants: Special care is needed when switching between different anticoagulants in patients with renal impairment

In summary, apixaban offers advantages over rivaroxaban in patients with impaired renal function due to its lower renal clearance and more favorable safety profile. For patients with severe renal impairment or on dialysis, apixaban is the preferred DOAC option, while rivaroxaban should be avoided in patients with CrCl <15 mL/min.