Anticoagulant | Features affecting selection | Mechanism, administration, and monitoring |
Argatroban | - Short-acting
- Can be used in CKD; no dose adjustment needed
- Eliminated hepatically; dose adjustment needed in liver impairment
- Can be used in pregnancy
- Use in breastfeeding unknown
| - Parenteral direct thrombin inhibitor
- Administered by continuous intravenous infusion
- Monitored and adjusted by aPTT; obtain aPTT prior to initiation, 2 hours after starting infusion, and after dose changes
- Half-life approximately 40 to 50 minutes (prolonged to approximately 180 minutes in hepatic impairment)
- Prolongs the PT/INR
- No reversal agent (but effect is rapidly reversed upon discontinuation)
- Expensive
|
Bivalirudin | - Short-acting
- Eliminated by the kidney; dose adjustment needed in CKD
- Can be used in liver impairment; no dose adjustment is needed
- Multi-organ failure in critical illness; dose adjustment is needed
- Can be used in pregnancy
- Use in breastfeeding unknown
| - Parenteral direct thrombin inhibitor
- Administered by continuous intravenous infusion
- Monitored and adjusted by aPTT; obtain aPTT prior to infusion, 2 hours after starting infusion, and after dose changes
- Half-life approximately 25 minutes (prolonged to approximately 3.5 hours in ESKD)
- Prolongs the PT/INR, less so than argatroban
- No reversal agent (but effect is rapidly reversed upon discontinuation)
- Expensive
|
Danaparoid (not available in United States) | - Parenteral agent; may be given subcutaneously following initial intravenous bolus
- Eliminated by the kidney; dose adjustment needed in CKD
- Can be used in liver impairment; no dose adjustment is needed
- Can be used in pregnancy
- Can be used in breastfeeding
| - Parenteral inhibitor of thrombin and factor Xa (indirect, heparinoid, derived from porcine intestine)
- Administered intravenously or subcutaneously (intravenous dosing preferred if an invasive procedure is likely to be needed)
- No routine coagulation test monitoring; anti-factor Xa activity can be monitored if needed*
- Half-life (anti-factor Xa activity) is approximately 25 hours; prolonged to 29 to 35 hours in CKD
- No reversal agent
|
Fondaparinux | - Subcutaneous agent
- Eliminated by the kidney; dose adjustment is needed for CrCl 30 to 50 mL/minute and should not be used if CrCl is <30 mL/minute
- Can be used in liver impairment; no dose adjustment is needed
- Not suitable if likely to undergo urgent invasive procedure due to long half-life
- Can be used in pregnancy
| - Parenteral inhibitor of factor Xa (indirect)
- Administered subcutaneously, once per day
- No routine coagulation test monitoring; anti-factor Xa activity can be monitored if needed*
- Half-life 17 to 21 hours; prolonged in renal impairment, older adults, and low body weight
- Possible reversal with andexanet alfa
|
Apixaban | - Oral agent
- Eliminated by the kidney and liver (less dependent on kidney function than other DOACs); no dose adjustment is needed for CrCl ≥25 mL/minute or mild to moderate hepatic impairment
- Do not use if CrCl <25 mL/minute, serum creatinine >2.5 mg/dL, dialysis-dependent, or severe hepatic impairment
- Subject to CYP3A4 and P-gp drug interactions
- Use in pregnancy and breastfeeding unknown
| - Oral direct factor Xa inhibitor
- Administered orally, twice-daily dosing (higher initial dose for VTE treatment)
- Half-life approximately 12 hours
- No routine coagulation test monitoring; anti-factor Xa activity can be monitored if needed*
- Reversal agent (andexanet alfa or PCC)
- Not dialyzable
|
Dabigatran | - Oral agent
- Mostly eliminated by the kidney; no dose adjustment needed for CrCl >30 mL/minute or liver impairment¶
- Do not use if CrCl ≤30 mL/minute or dialysis-dependent
- Subject to P-gp drug interactions
- Use in pregnancy and breastfeeding unknown
| - Oral direct thrombin inhibitor
- Administered orally, twice-daily dosing (initial parenteral agent for VTE treatment)
- Half-life 12 to 17 hours; prolonged up to 28 hours in severe renal impairment
- No routine coagulation test monitoring; refer to UpToDate for monitoring in selected cases
- Reversal agent (idarucizumab)
|
Edoxaban | - Oral agent
- Eliminated by the kidney and liver; no dose adjustment required for CrCl >50 mL/minute or mild liver impairment
- Dose adjustment is needed for CrCl 15 to 50 mL/minute
- Do not use if CrCl ≤15 mL/minute or >95 mL/minute, dialysis-dependent, or moderate to severe liver impairment
- Dose adjustment needed for body weight ≤60 kg
- Subject to P-gp drug interactions
- Use in pregnancy and breastfeeding unknown
| - Oral direct factor Xa inhibitor
- Administered orally, once-daily dosing (initial parenteral agent for VTE treatment)
- Half-life 10 to 14 hours; prolonged in renal impairment
- No routine coagulation test monitoring; anti-factor Xa activity can be monitored if needed*
- Reversal agent (andexanet alfa or PCC)
|
Rivaroxaban | - Eliminated by the kidney and liver; no dose adjustment is needed for CrCl >30 mL/minute or mild liver impairment
- Do not use if CrCl ≤30 mL/minute, dialysis-dependent, or moderate to severe hepatic impairment
- Subject to CYP3A4 and P-gp drug interactions
- Use in pregnancy and breastfeeding unknown
| - Oral direct factor Xa inhibitor
- Administered orally, once-daily dosing (initial twice-daily dosing for VTE treatment)
- Half-life 5 to 9 hours
- No routine monitoring; anti-factor Xa activity can be monitored if needed*
- Reversal agent (andexanet alfa or PCC)
|
Warfarin | - Cannot be used until stable anticoagulation with another non-heparin anticoagulant has been established and the platelet count has normalized or returned to baseline
- Can be used in severe kidney or liver impairment; monitor INR closely
- Many drug and dietary interactions
- Can be used in patients with a mechanical heart valve
- Teratogen: Avoid in first trimester of pregnancy unless benefits outweigh risks (eg, mechanical heart valve)
| - Oral vitamin K antagonist, interferes with synthesis of thrombin and factors VII, IX, and X
- Administered orally, once-daily dosing with regular monitoring and dose adjustments based on the PT/INR
- Requires at least five consecutive days of overlapping non-heparin anticoagulant that is continued until the INR is therapeutic
- If transitioning from argatroban to warfarin, refer to institutional guidelines for INR target as both agents elevate the INR
- Reversal agent (vitamin K and PCC)
- Inexpensive
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