『S4E2 - The Kidney Formula Conundrum: Navigating eCrCl vs. eGFR in DOAC Dosing』のカバーアート

S4E2 - The Kidney Formula Conundrum: Navigating eCrCl vs. eGFR in DOAC Dosing

S4E2 - The Kidney Formula Conundrum: Navigating eCrCl vs. eGFR in DOAC Dosing

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 Welcome back to What's it Worth! Join your hosts, Dr. Diana Langworthy and guest Dr. Rachel Khan (Associate Professor at VCU School of Pharmacy), as they navigate the murky waters of renal function assessment in anticoagulant users. This episode dissects a critical insight from the ORBIT-AF II registry: the variability in DOAC (NOAC) dose eligibility when labs use newer kidney estimates . While clinical trials used Cockcroft-Gault (eCrCl), modern labs often report eGFR (MDRD or CKD-EPI), leading to a "renal identity crisis" for clinicians . We're putting on our EBP detective hats to explore why these formulas disagree—and what that means for your patients. Let's dive in and see what it's worth! Key Points The Gold Standard Gap: Landmark DOAC trials and product monographs almost exclusively use Cockcroft-Gault (eCrCl) for dosing, yet clinical labs have moved toward automated eGFR reporting . Formula Discordance: In the ORBIT-AF II cohort, agreement between eCrCl and eGFR was high overall (~93%), but declined in patients with established chronic kidney disease (CKD) . The "Misclassification" Mystery: Up to 42% of CKD patients could be classified for a different dose depending on which formula is used, with rivaroxaban showing the highest rates of variability . The Interpretive Challenge: While the study noted an association between formula-driven "undertreatment" and worse outcomes, we discuss the critical limitations—such as the lack of BSA-adjusted eGFR data—that make it difficult to conclude that eGFR is directly leading us to miss our target doses. Is your patient truly underdosed, or are we just using the wrong yardstick? ------> Tune in to find out! References [EPISODE TRIAL] Yao RJR, Holmes DN, Andrade JG, et al. Variability in Nonvitamin K Oral Anticoagulant Dose Eligibility and Adjustment According to Renal Formulae and Clinical Outcomes in Patients With Atrial Fibrillation With and Without Chronic Kidney Disease: Insights From ORBIT-AF II. J Am Heart As soc. 2023 Mar 21;12(6):e026605. doi: 10.1161/JAHA.122.026605. St Peter WL, Bzowyckyj AS, Anderson-Haag T, et al; Moving forward from Cockcroft-Gault creatinine clearance to race-free estimated glomerular filtration rate to improve medication-related decision-making in adults across healthcare settings: A consensus of the National Kidney Foundation Workgroup for Implementation of Race-Free eGFR-Based Medication-Related Decisions. Am J Health Syst Pharm. 2025 Jun 11;82(12):644-659.Möller E, McIntosh JF, Van Slyke DD. STUDIES OF UREA EXCRETION. II: Relationship Between Urine Volume and the Rate of Urea Excretion by Normal Adults. J Clin Invest. 1928 Dec;6(3):427-65. doi: 10.1172/JCI100206. PMID: 16693839; PMCID: PMC434761.U.S. Food and Drug Administration (FDA). Pharmacokinetics in Patients with Impaired Renal Function — Study Design, Data Analysis, and Impact on Dosing and Labeling: Guidance for Industry. March 2024. Accessed December 2025. Contact Information Podcast email: whatsitworthpodcast@gmail.com Host Information Dr. Diana R. Langworthy, PharmD, BCPS Clinical Associate Professor, University of Minnesota College of Pharmacy Clinical Pharmacist - Inpatient Internal Medicine, M Health Fairview East Bank Hospital Guest Information Dr. Rachel Khan, PharmD, BCPS Associate Professor, VCU School of Pharmacy Clinical Pharmacist - Internal Medicine, VCUHS
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