10th July 2026

Anticoagulants

Recommendations for DOACs in adults with renal impairment

• End-stage renal impairment CrCl <15 mL / min
  • Dabigatran, Apixaban, Edoxaban and Rivaroxaban are all either contraindicated or not recommended.
• Severe renal impairment (CrCl 15 to 29 mL per minute) 
  • Dabigatran is contraindicated. 
  • Depending on clinical requirements, dose reductions are required for apixaban, edoxaban and rivaroxaban. 
• Moderate renal impairment (CrCl 30 to 49 mL per minute)
  • Dose adjustments required for dabigatran, apixaban, edoxaban and rivaroxaban.
• Mild renal impairment (CrCl 50 to 80 mL per minute)
  • Dose adjustment only required for apixaban in patients for prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. 

Heparin

Low molecular weight heparins are excreted renally, and accumulation can therefore occur. Dose reductions are required usually for creatinine clearance <30 mL/min.  An alternative anticoagulant, such as unfractionated heparin may be preferred, especially for individuals with CrCl <30 mL/min, with renal failure, or receiving dialysis. Examples of alternatives include: 

• Unfractionated heparin
• An LMW heparin with lower renal clearance
• A DOAC with low renal clearance (apixaban, renal clearance approximately 25%) 

Use of LMW heparin in patients with renal insufficiency has been associated with hyperkalemia.