- Select the drug (apixaban, rivaroxaban, dabigatran, or edoxaban) and the indication (non-valvular AF stroke prevention, VTE treatment, or VTE prophylaxis).
- Enter age, sex, body weight (kg), and serum creatinine (mg/dL). The tool computes Cockcroft-Gault creatinine clearance — the metric used by DOAC labels (not eGFR).
- The recommended dose updates automatically. For apixaban in AF, the dose-reduction criteria (age ≥80, weight ≤60 kg, SCr ≥1.5 mg/dL) are evaluated from the same inputs.
- Colour flags the result: green = standard dose, amber = reduced dose, red = avoid / not recommended (including the edoxaban CrCl >95 efficacy warning).
Rules follow US FDA prescribing information. Regional labels (EMA/local) may differ. All computation runs in your browser; no values are stored or transmitted.
When to Use
Use this tool when starting, continuing, or re-checking a direct oral anticoagulant (DOAC) in a patient with reduced or changing kidney function. All four agents are renally cleared to differing degrees — dabigatran ~80%, edoxaban ~50%, rivaroxaban ~36%, apixaban ~27% — so the labeled dose, and in some cases the decision to use the drug at all, depends on the creatinine clearance estimated by the Cockcroft-Gault equation. Enter the drug, indication, and patient data to get the FDA-labeled recommendation and any avoid/contraindicated or special-population flags.
Appropriate population
Adults considered for a DOAC for non-valvular atrial fibrillation stroke prevention or for venous thromboembolism (VTE) treatment or prophylaxis. Most useful in CKD, the elderly, low body weight, or where renal function is borderline for a dose cutoff.
When NOT to rely on it
This tool encodes US FDA label dosing for the listed indications only. It does not apply to mechanical heart valves or moderate-to-severe mitral stenosis (DOACs are not indicated), to drug–drug interaction adjustments beyond those noted (strong dual P-gp/CYP3A4 inhibitors or inducers), to obesity/extremes of weight where DOAC data are limited, or to pediatric, pregnant, or hepatically impaired patients. Regional labels may set different cutoffs. Confirm against the current prescribing information.
Pearls & Pitfalls
Use Cockcroft-Gault, not eGFR
Every DOAC pivotal trial and FDA label defines renal dosing by creatinine clearance estimated with the Cockcroft-Gault equation, which uses actual body weight. Substituting a CKD-EPI/MDRD eGFR (mL/min/1.73 m²) can misclassify a patient at a dose cutoff — particularly at the extremes of body size and in the elderly. Use the labeled metric.
Edoxaban is unusual at high CrCl
Edoxaban should be avoided in AF when CrCl >95 mL/min — in ENGAGE AF-TIMI 48 these patients had a higher rate of ischemic stroke on edoxaban 60 mg than on warfarin (lower drug exposure with better renal clearance). It is the only DOAC with an upper renal cutoff.
Apixaban reduction needs ≥2 of 3
For AF, apixaban is reduced to 2.5 mg BID only when at least two of these are present: age ≥80, weight ≤60 kg, SCr ≥1.5 mg/dL. A single criterion alone does not warrant reduction — under-dosing is associated with worse outcomes. (The HD-specific label allows reduction with age ≥80 OR weight ≤60 kg.)
Pitfalls
(1) Re-check CrCl whenever renal function changes (acute illness, volume shifts, AKI) — a stable-CKD dose can become inappropriate. (2) Check for strong P-gp / CYP3A4 interactions, which alter dabigatran, rivaroxaban, and edoxaban handling and may mandate reduction or avoidance. (3) In advanced CKD/ESKD on dialysis, DOAC data are limited; warfarin remains a reasonable option (dabigatran and rivaroxaban VTE dosing are not recommended at low CrCl; apixaban carries an HD label but with limited evidence). (4) These are US FDA rules — verify the regional label and the full clinical picture before prescribing.
Why Use It
DOAC dosing errors are common and consequential. Over-dosing in renal impairment raises bleeding risk, while under-dosing for AF — the more frequent error — is associated with higher rates of stroke, hospitalization, and death without a reliable reduction in bleeding. Because each agent has its own renal pharmacokinetics and its own cutoffs, the correct dose hinges on getting the creatinine clearance right (by Cockcroft-Gault) and on applying drug- and indication-specific rules consistently. This tool consolidates the four label algorithms into a single auditable calculation, flags the special situations clinicians most often miss — the apixaban ≥2-of-3 reduction rule and the edoxaban high-CrCl efficacy warning — and surfaces when a drug should be avoided altogether, supporting safer, label-concordant prescribing.
DOAC Dose Adjustment in Renal Impairment
Select the drug and indication, then enter the patient data. The tool computes Cockcroft-Gault creatinine clearance and returns the FDA-labeled dose with any avoid/contraindicated or special-population flags.
⚕ Dosing reflects US FDA prescribing information (Eliquis, Xarelto, Pradaxa, Savaysa). Renal cutoffs use Cockcroft-Gault creatinine clearance, not eGFR. This tool does not account for drug–drug interactions (strong P-gp / CYP3A4 inhibitors or inducers) beyond noted flags, hepatic impairment, extremes of body weight, mechanical valves, or non-FDA regional labels. For licensed clinicians; verify against the current label and individualize.
Next Steps
Translate the CrCl and labeled dose into a prescribing decision and a monitoring plan.
- Confirm the renal estimate. Verify CrCl with the Cockcroft-Gault calculator and reassess at every visit and with any change in renal function (illness, volume status, AKI).
- Reconcile interactions. Screen for strong P-gp and CYP3A4 inhibitors/inducers; dabigatran, rivaroxaban, and edoxaban handling can change enough to require reduction or avoidance.
- Reassess indication and bleeding risk. Pair the AF decision with the CHA₂DS₂-VASc score; weigh bleeding risk and shared decision-making before anticoagulating.
- At advanced CKD/ESKD or a low-CrCl avoid threshold, consider warfarin (with INR monitoring) or specialist input — DOAC outcome data are limited in this population.
- For the full library, see all calculators & tools.
Evidence & References
Creatinine clearance (Cockcroft-Gault)
| Quantity | Formula |
|---|---|
| CrCl (mL/min) | [(140 − age) × weight(kg) × (0.85 if female)] ÷ (72 × SCr mg/dL) |
FDA-labeled renal dosing — Atrial Fibrillation (stroke prevention)
| Drug | Dose by renal function |
|---|---|
| Apixaban | 5 mg BID; 2.5 mg BID if ≥2 of: age ≥80, weight ≤60 kg, SCr ≥1.5 mg/dL. No CrCl cutoff in label (HD label exists, limited data). |
| Rivaroxaban | CrCl >50: 20 mg daily with evening meal · CrCl 15–50: 15 mg daily · CrCl <15: avoid. |
| Dabigatran | CrCl >30: 150 mg BID · CrCl 15–30: 75 mg BID · CrCl <15 or dialysis: not recommended. |
| Edoxaban | CrCl >95: AVOID (↑ischemic stroke) · CrCl 51–95: 60 mg daily · CrCl 15–50: 30 mg daily · CrCl <15: not recommended. |
FDA-labeled renal dosing — VTE treatment / prophylaxis
| Drug | Treatment | Prophylaxis |
|---|---|---|
| Apixaban | 10 mg BID ×7 days, then 5 mg BID | 2.5 mg BID |
| Rivaroxaban | 15 mg BID ×21 days, then 20 mg daily (CrCl ≥15; caution <30) | 10 mg daily |
| Dabigatran | 150 mg BID after parenteral lead-in (CrCl >30; ≤30 avoid) | 150 mg BID (CrCl >30) |
| Edoxaban | 60 mg daily; 30 mg if CrCl 15–50, weight ≤60 kg, or strong P-gp inhibitor | — |
Renal cutoffs use Cockcroft-Gault creatinine clearance. The apixaban AF reduction requires at least two of the three criteria; edoxaban uniquely carries an upper CrCl boundary (>95 mL/min) above which efficacy for AF is reduced.
References
- Eliquis (apixaban) US Prescribing Information. Bristol-Myers Squibb/Pfizer.
- Xarelto (rivaroxaban) US Prescribing Information. Janssen Pharmaceuticals.
- Pradaxa (dabigatran etexilate) US Prescribing Information. Boehringer Ingelheim.
- Savaysa (edoxaban) US Prescribing Information. Daiichi Sankyo.
- January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for the Management of Patients With Atrial Fibrillation. Circulation. 2019;140(2):e125–e151.
- Steffel J, Collins R, Antz M, et al. 2021 EHRA Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation. Europace. 2021;23(10):1612–1676.
