A 70-year-old man with permanent atrial fibrillation, hypertension, diabetes, and eGFR 40 mL/min is being anticoagulated. CHA₂DS₂-VASc score is 5. Which oral anticoagulant is most appropriate?
- A Apixaban 5 mg BD (or 2.5 mg BD if dose-reduction criteria met) ✓
- B Warfarin with INR target 2–3
- C Rivaroxaban 20 mg OD
- D Dabigatran 150 mg BD
Correct answer: A. Apixaban 5 mg BD (or 2.5 mg BD if dose-reduction criteria met)
Explanation
In AF patients with CKD (eGFR 30–50 mL/min), apixaban is preferred over other DOACs based on the ARISTOTLE trial showing superior efficacy and safety compared to warfarin. ENGAGE AF-TIMI and ROCKET-AF showed rivaroxaban and dabigatran have less favourable renal pharmacokinetics; dabigatran is 80% renally excreted and should be avoided at eGFR <30 (with caution 30–50). Apixaban dose reduction criteria (2.5 mg BD): two of three — age ≥80, weight ≤60 kg, serum creatinine ≥1.5 mg/dL. Warfarin is acceptable but DOACs are preferred for non-valvular AF.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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