Direct Oral Anticoagulant Dosing in Patients With Atrial Fibrillation: An Asian Perspective

Tze-Fan Chao; Ngai-Yin Chan; Yi-Hsin Chan; Min-Soo Cho; Rungroj Krittayaphong; Kwang-No Lee; Shaowen Liu; Tachapong Ngamukos; Hung-Fat Tse

doi:10.1016/j.jacasi.2023.08.007

Direct Oral Anticoagulant Dosing in Patients With Atrial Fibrillation: An Asian Perspective

JACC Asia. 2023 Oct 17;3(5):707-723. doi: 10.1016/j.jacasi.2023.08.007. eCollection 2023 Oct.

Authors

Tze-Fan Chao¹, Ngai-Yin Chan², Yi-Hsin Chan³, Min-Soo Cho⁴, Rungroj Krittayaphong⁵, Kwang-No Lee⁶, Shaowen Liu⁷, Tachapong Ngamukos⁸, Hung-Fat Tse⁹

Affiliations

¹ Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan.
² Department of Medicine and Geriatrics, Princess Margaret Hospital, Lai Chi Kok, Hong Kong SAR.
³ Microscopy Core Laboratory, Linkou Chang Gung Memorial Hospital, Linkou, Taiwan.
⁴ Department of Cardiology, Center for Medical Research and Information, Asan Medical Center, Seoul, South Korea.
⁵ Division of Cardiology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
⁶ Division of Cardiology, Department of Internal Medicine, Ajou University Hospital and Ajou School of Medicine, Suwon, South Korea.
⁷ Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
⁸ Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
⁹ Department of Medicine, The University of Hong Kong, Hong Kong SAR.

Abstract

Optimal dosing of direct oral anticoagulants (DOACs) for stroke prevention in "gray area" patients with atrial fibrillation (AF) remains a challenge for clinicians. In Asia, this is concerning in patients who are very elderly, have low body weight, and are at a high risk of bleeding. This review aims to summarize the dose reduction criteria for DOACs, discuss the evidence on dosing of DOACs across Asian regions, and collate opinions from authors across Asia. Nonrecommended dosing of DOACs is common in Asia, primarily due to the fear of bleeding, with the total clinical benefit of higher dosing being overlooked. The ELDERCARE-AF (Edoxaban Low-Dose for Elder Care-Atrial Fibrillation Patients) trial and real-world case studies provide some evidence on the use of low-dose DOACs in gray area patients. Opinions on dose adjustment guidance, concomitant medication adjustments, and therapeutic drug monitoring were collated. Research is needed to fill the evidence gaps on optimal DOAC doses for gray area patients.

Keywords: Asia; atrial fibrillation; direct oral anticoagulant; dose; elderly; low body weight.

Publication types

Review