BACKGRUND: The direct oral anticoagulants (DOAC) are increasingly used for primary and secondary stroke prophylaxis in atrial fibrillation, although their use in patients with renal failure is problematic. CASE REPORT: In an 82-years old female with recurrent strokes and atrial fibrillation, the vitamin-K-antagonist was changed to rivaroxaban because of "unstable international normalized ratio (INR) values". Because of renal failure with a creatinine clearance of 32ml/min, a dosage of rivaroxaban 10mg/d was chosen. Eleven days after initiation of rivaroxaban, she was re-hospitalized because of acute onset of right-sided weakness of the upper and lower limbs. CONCLUSIONS: In cases of stroke, renal failure and inadequate anticoagulation it is not useful to change from vitamin-K-antagonists to "low dose" DOAC. Diligent investigations for the cause of INR-instability and continuation of vitamin-K-antagonist therapy seem to be more effective and safer since there is the opportunity of monitoring therapy and to avoid under- as well as over-dosage.
BACKGRUND: The direct oral anticoagulants (DOAC) are increasingly used for primary and secondary stroke prophylaxis in atrial fibrillation, although their use in patients with renal failure is problematic. CASE REPORT: In an 82-years old female with recurrent strokes and atrial fibrillation, the vitamin-K-antagonist was changed to rivaroxaban because of "unstable international normalized ratio (INR) values". Because of renal failure with a creatinine clearance of 32ml/min, a dosage of rivaroxaban 10mg/d was chosen. Eleven days after initiation of rivaroxaban, she was re-hospitalized because of acute onset of right-sided weakness of the upper and lower limbs. CONCLUSIONS: In cases of stroke, renal failure and inadequate anticoagulation it is not useful to change from vitamin-K-antagonists to "low dose" DOAC. Diligent investigations for the cause of INR-instability and continuation of vitamin-K-antagonist therapy seem to be more effective and safer since there is the opportunity of monitoring therapy and to avoid under- as well as over-dosage.