A 72-year-old man with persistent atrial fibrillation (AF) has a CHA₂DS₂-VASc score of 4 (age 72, hypertension, diabetes, prior TIA). He is started on a NOAC. Which NOAC is preferred in patients with non-valvular AF and CKD stage 3b (eGFR 38 mL/min)?
- A Dabigatran 150 mg twice daily
- B Apixaban 5 mg twice daily ✓
- C Rivaroxaban 20 mg once daily
- D Edoxaban 60 mg once daily
Correct answer: B. Apixaban 5 mg twice daily
Explanation
Among NOACs, apixaban has the lowest renal elimination (27%) and does not require dose reduction until CrCl falls below 25 mL/min (using specific criteria: serum creatinine ≥1.5 mg/dL with age ≥80 or weight ≤60 kg). The ARISTOTLE trial showed apixaban superior to warfarin in stroke prevention with lower bleeding rates including in CKD patients. Dabigatran is 80% renally eliminated and is contraindicated/dose-reduced below eGFR 30 mL/min; caution at eGFR 30–50. Rivaroxaban (33% renal) and edoxaban (50% renal) also require dose adjustment with lower GFR.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.