Avoid GP IIb/IIIa inhibitor if possible; thrombotic risk following discontinuation. Rivaroxaban 35% cleared renally; 65% hepatic (CYP3A4); levels in hepatic and/or renal dysfunction and age Bleeding risk; not reversible CrCl 15 49 mL/min: 15 mg QD; consider avoiding if CrCl 15 30 mL/min if bleeding risk; CrCl >50 mL/min: 20 mg QD Some drug interactions Dabigatran 80% cleared renally; plasma level with age, especially Bleeding risk; not reversible CrCl 15 30 mL/min: 75 mg BID with caution; CrCl 30 49 mL/min: 75 mg BID; CrCl >50 mL/min: 150 mg BID Monitor pt and renal function frequently; longest for effect to wane with CrCl; risk dyspepsia, GI bleeding Apixaban Hepatically cleared (minor CYP3A4); dose adjust if weight 60 kg; highly protein bound Bleeding risk; not reversible CrCl 15 29 mL/min: 2.5 mg BID or with 2 of the following: age 80 y/weight 60 kg/SCr 1.5 mg/ dL: SCr <1.5: 5 mg BID Risk abnormal liver function tests *CrCl should be calculated for all older pts because SCr level does not accurately reflect renal dysfunction: CrCl decreases with age 0.7 mL/min/y. These agents are not approved for NSTE-ACS but are included for management of pts with nonvalvular chronic atrial fibrillation. 