5 mg BID (2.5 mg BID if ≥2 of: age ≥80, ≤60 kg, SCr ≥1.5)
10 mg BID ×7 d → 5 mg BID
2.5 mg BID
Rivaroxaban
20 mg QD with evening meal
15 mg BID ×21 d → 20 mg QD (with food)
10 mg QD
Dabigatran
150 mg BID
150 mg BID after ≥5 d parenteral
150 mg BID
Edoxaban
60 mg QD (30 mg if CrCl 15–50, ≤60 kg, or P-gp inhib)
60 mg QD after ≥5 d parenteral
60 mg QD
Renal Adjustment (AF)
StandardAdjustAvoid / caution
Drug
CrCl >50
CrCl 30–50
CrCl 15–30
CrCl <15 / HD
Apixaban
Standard
Standard*
Use SCr criteria
5 mg BID (2.5 if age ≥80 or ≤60 kg), FDA-labeled
Rivaroxaban
Standard
Standard
15 mg QD w/ meal
Avoid
Dabigatran
Standard
Standard
75 mg BID
Avoid (<15)
Edoxaban
Standard
30 mg QD
30 mg QD
Avoid
*Apixaban: use the SCr-based dose-reduction criteria. Edoxaban is contraindicated for AF when CrCl >95 (reduced efficacy, ENGAGE AF-TIMI 48; FDA boxed warning).
Reversal of Major Bleeding
DOAC
Agent
Dose
Apixaban / Rivaroxaban
4-factor PCC (Kcentra)
~50 units/kg IV for life-threatening bleeding (protocols vary)
Dabigatran
Idarucizumab (Praxbind)
5 g IV (two 2.5 g vials)
⚠ Andexanet alfa (Andexxa) was withdrawn from the US market (Dec 2025) after ANNEXA-I showed net thrombotic harm. 4-factor PCC is now the practical Xa-inhibitor reversal option. Add tranexamic acid + supportive care; hold the DOAC; consider activated charcoal if last dose <2–4 h.
Red Flags & Pearls
🛑
Mechanical heart valve or moderate–severe mitral stenosis: DOACs are contraindicated. Warfarin only.
🍞
Take with food: rivaroxaban 15/20 mg and edoxaban require food for absorption, a common adherence failure point.
CKD/HD: apixaban has the least renal elimination and is the preferred DOAC across CrCl 15–30 and the only one FDA-labeled for HD.
⚡
Interactions: avoid with strong dual P-gp + CYP3A4 inducers (rifampin, carbamazepine) or inhibitors (azoles, ritonavir). No routine PT/INR monitoring. Dabigatran alone tracks with dTT/ECT.