What anticoagulant is recommended for a 93-year-old female with impaired renal function and a history of thrombotic cerebrovascular accident (CVA)?

Anticoagulation Recommendation for 93-Year-Old Female with eGFR 31 and Thrombotic CVA

Apixaban 2.5 mg twice daily is the recommended anticoagulant for this 93-year-old female with eGFR 31 and thrombotic CVA. 1, 2

Rationale for Anticoagulant Selection

Patient Risk Factors

• Advanced age (93 years) - high risk for bleeding 1
• Moderate renal impairment (eGFR 31 ml/min) - affects drug clearance 1
• History of thrombotic CVA - indicates need for anticoagulation 1

Preferred Anticoagulant: Apixaban

• Apixaban has the lowest renal clearance (27%) among direct oral anticoagulants (DOACs), making it safer in patients with renal impairment 1
• The relative safety of apixaban vs. warfarin has been demonstrated to increase with decreasing renal function 1
• Dose reduction to 2.5 mg twice daily is appropriate based on age >80 years and renal impairment 1, 2
• FDA-approved for use in patients with eGFR >15 ml/min 2

Dosing Considerations

Apixaban Dose Adjustment

• Standard dose: 5 mg twice daily 2
• Reduced dose (2.5 mg twice daily) recommended when patient has at least 2 of the following: 1, 2
  • Age ≥80 years (patient is 93) ✓
  • Body weight ≤60 kg (unknown in this case)
  • Serum creatinine ≥1.5 mg/dL (likely elevated with eGFR 31) ✓

Monitoring Requirements

• Regular assessment of renal function is essential 1
• Evaluate renal function before initiation and at least annually 1
• No routine coagulation monitoring required 1

Alternative Options

Edoxaban

• Second-best option with 50% renal clearance 1
• Would require dose reduction to 30 mg daily with eGFR <50 ml/min 1
• Less clinical experience in very elderly patients compared to apixaban 1

Rivaroxaban

• 33% renal clearance 1
• Would require dose reduction to 15 mg daily with eGFR <50 ml/min 1
• Higher bleeding risk compared to apixaban in elderly patients 1

Warfarin

• Not preferred due to:
  • Higher risk of anticoagulant-related nephropathy in patients with CKD 1
  • Increased risk of calciphylaxis in patients with renal failure 1
  • Challenging INR management in elderly patients 1
  • Higher bleeding risk compared to DOACs in CKD patients 1

Important Considerations

Bleeding Risk Management

• Monitor for signs of bleeding, particularly gastrointestinal and intracranial 1, 3
• Consider gastroprotection with proton pump inhibitors if additional risk factors for GI bleeding 1
• Avoid concomitant antiplatelet therapy unless absolutely necessary 1

Follow-up and Monitoring

• Regular clinical assessment for efficacy and adverse effects 1
• Periodic reassessment of renal function 1
• Evaluate need for continued anticoagulation at regular intervals 1

Contraindications and Cautions

• Apixaban should be avoided if eGFR <15 ml/min 1, 2
• Use with caution in patients with history of GI bleeding 1
• Avoid in patients with severe hepatic impairment 1, 2

Conclusion

For this 93-year-old female with eGFR 31 and thrombotic CVA, apixaban 2.5 mg twice daily provides the optimal balance of efficacy and safety given her age and renal function. The lower renal clearance of apixaban compared to other DOACs makes it particularly suitable for patients with moderate renal impairment, and its established safety profile in elderly patients further supports this recommendation. 1, 2