| Course | DNRS 6521 Advanced Pharmacology (DNP level) |
|---|---|
| Week | Week 4 |
| Paper type | Decision case paper |
| Length | About 1,020 words, 6 pages |
| Format | APA 7 student paper |
| School | Walden University |
| Program | Doctor of Nursing Practice (DNP) |
| Updated | October 2026 |
Free sample paper for DNRS 6521 Week 4
Decision Case: Continue Warfarin or Switch to Apixaban for an 84-Year-Old Woman With Atrial Fibrillation and a Creatinine Clearance of 22 mL/min
Student Name
College of Nursing, Walden University
DNRS 6521: Advanced Pharmacology (DNP level)
Instructor Name
Month Day, Year
Decision Case: Continue Warfarin or Switch to Apixaban for an 84-Year-Old Woman With Atrial Fibrillation and a Creatinine Clearance of 22 mL/min
The Presentation
A composite 84-year-old woman has permanent atrial fibrillation, hypertension, and a stroke-risk score that makes anticoagulation clearly indicated. She has taken warfarin for 6 years. At 57 kg with a serum creatinine of 1.8 mg/dL, she has an estimated creatinine clearance of 22 mL/min using the Cockcroft-Gault formula (Cockcroft & Gault, 1976). Over the past year, her international normalized ratio (INR) was in the therapeutic range 48% of the time despite monthly testing, with two values above 4. Two years ago she had an upper gastrointestinal bleed while taking aspirin with warfarin; the aspirin was stopped. She lives alone, drives to the clinic for INR checks, and her daughter asks whether a newer drug would mean fewer visits.
The Criteria, Named Before They Are Applied
Four criteria will decide between continuing warfarin and switching to apixaban, and they are named first so the reader can audit the result. First, evidence for preventing stroke at her level of kidney function. Second, major and intracranial bleeding risk. Third, the predictability of anticoagulant effect in her. Fourth, the burden and practicality of the regimen for her. Each criterion is justified: the first and second are the outcomes anticoagulation exists to balance, the third reflects how she has actually done on warfarin, and the fourth reflects that a regimen she cannot sustain protects no one.
Option A: Continue Warfarin
Evidence at her kidney function. Warfarin is not cleared by the kidney, and its dose is set by INR regardless of creatinine clearance. It has been used across all levels of kidney function, and the atrial fibrillation guideline considers warfarin reasonable in advanced chronic kidney disease (Joglar et al., 2024).
Bleeding. In the large randomized trials, warfarin carried more intracranial hemorrhage than the direct oral anticoagulants; a meta-analysis found that the newer drugs roughly halved intracranial hemorrhage compared with warfarin (Ruff et al., 2014).
Predictability. This is where warfarin performs worst for her. Time in the therapeutic range of 48% means she spends about half her time either underprotected or overanticoagulated, and her two INR values above 4 are the kind of excursion that precedes bleeding.
Burden. Monthly INR visits, dose adjustments, and dietary attention continue. She manages them, but with effort.
Option B: Switch to Apixaban
Evidence at her kidney function. In the ARISTOTLE trial, apixaban reduced stroke or systemic embolism, major bleeding, and death compared with warfarin (Granger et al., 2011), and its bleeding advantage was larger in patients with reduced kidney function (Hohnloser et al., 2012). In the trial's small group with creatinine clearance of 25 to 30 mL/min, apixaban caused less major bleeding than warfarin (Stanifer et al., 2020). But ARISTOTLE excluded patients with a creatinine clearance below 25 mL/min, so at 22 she is outside the randomized evidence. Observational data in patients on dialysis found less major bleeding with apixaban than warfarin and no difference in stroke (Siontis et al., 2018). The evidence at her kidney function is therefore indirect.
Bleeding. The direction of evidence favors apixaban, as above.
Predictability. Apixaban is cleared partly by the kidney, about a quarter of a dose, so exposure rises modestly as clearance falls. She meets three of the labeled criteria for the reduced dose, her age past 80, her body weight under 60 kg, and a creatinine of at least 1.5 mg/dL, so the labeled dose for her is 2.5 mg twice daily. Its effect does not depend on diet or on an INR she struggles to keep in range.
Burden. No routine INR testing and fewer interactions with food. Twice-daily dosing matters, because missed doses of a short-acting drug leave gaps in protection; she uses a weekly pill organizer already.
What Carried the Decision
The decision is to switch to apixaban 2.5 mg twice daily, and one criterion carried it: bleeding. Her labile INR, her prior gastrointestinal bleed, and her age together make intracranial and major bleeding her most serious risk, and every source that speaks to it, randomized, subgroup, and observational, points the same direction. The American Geriatrics Society Beers Criteria also advise against warfarin as a first choice for atrial fibrillation in older adults unless direct oral anticoagulants are contraindicated (American Geriatrics Society Beers Criteria Update Expert Panel, 2023).
A reasonable colleague could weight the first criterion more heavily and land elsewhere. Her creatinine clearance of 22 mL/min lies outside the randomized trial, and a clinician who requires randomized evidence at a patient's exact kidney function would keep her on warfarin and work to improve her time in range. That is a defensible position. I weight bleeding more because her actual record on warfarin is known and poor, while the uncertainty about apixaban below 25 mL/min is real but has not, in the evidence available, pointed toward harm.
Monitoring and Reassessment
Warfarin is stopped and apixaban started when the INR falls below 2.0. Kidney function, hemoglobin, and weight are checked at 1 month and then every 3 months, because a further fall in clearance or a change in weight alters exposure and the dose criteria. Any bleeding, a fall in hemoglobin of at least 2 g/dL, or a creatinine clearance below 15 mL/min prompts review of the choice. Her daughter will help set up the pill organizer and will be told that missed doses matter more with apixaban than with warfarin.
Reassessment is planned, not only triggered. At 6 months, the choice is reviewed as a whole: whether she has taken the drug reliably, whether any bleeding occurred, and whether her kidney function has held. If her clearance continues to fall toward the range where no randomized evidence exists for any oral anticoagulant, the conversation turns to her own priorities, including whether the burden and risk of anticoagulation still fit her goals. That conversation is easier to have at a scheduled review than after a bleed. Her record will carry a note that the apixaban dose depends on her age, weight, and creatinine, so that any clinician who sees a change in one of them knows to recheck it.
References
American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372
Cockcroft, D. W., & Gault, M. H. (1976). Prediction of creatinine clearance from serum creatinine. Nephron, 16(1), 31-41. https://doi.org/10.1159/000180580
Granger, C. B., Alexander, J. H., McMurray, J. J. V., Lopes, R. D., Hylek, E. M., Hanna, M., Al-Khalidi, H. R., Ansell, J., Atar, D., Avezum, A., Bahit, M. C., Diaz, R., Easton, J. D., Ezekowitz, J. A., Flaker, G., Garcia, D., Geraldes, M., Gersh, B. J., Golitsyn, S., . . . Wallentin, L. (2011). Apixaban versus warfarin in patients with atrial fibrillation. The New England Journal of Medicine, 365(11), 981-992. https://doi.org/10.1056/NEJMoa1107039
Hohnloser, S. H., Hijazi, Z., Thomas, L., Alexander, J. H., Amerena, J., Hanna, M., Keltai, M., Lanas, F., Lopes, R. D., Lopez-Sendon, J., Granger, C. B., & Wallentin, L. (2012). Efficacy of apixaban when compared with warfarin in relation to renal function in patients with atrial fibrillation: Insights from the ARISTOTLE trial. European Heart Journal, 33(22), 2821-2830. https://doi.org/10.1093/eurheartj/ehs274
Joglar, J. A., Chung, M. K., Armbruster, A. L., Benjamin, E. J., Chyou, J. Y., Cronin, E. M., Deswal, A., Eckhardt, L. L., Goldberger, Z. D., Gopinathannair, R., Gorenek, B., Hess, P. L., Hlatky, M., Hogan, G., Ibeh, C., Indik, J. H., Kido, K., Kusumoto, F., Link, M. S., . . . Van Wagoner, D. R. (2024). 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 149(1), e1-e156. https://doi.org/10.1161/CIR.0000000000001193
Ruff, C. T., Giugliano, R. P., Braunwald, E., Hoffman, E. B., Deenadayalu, N., Ezekowitz, M. D., Camm, A. J., Weitz, J. I., Lewis, B. S., Parkhomenko, A., Yamashita, T., & Antman, E. M. (2014). Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: A meta-analysis of randomised trials. The Lancet, 383(9921), 955-962. https://doi.org/10.1016/S0140-6736(13)62343-0
Siontis, K. C., Zhang, X., Eckard, A., Bhave, N., Schaubel, D. E., He, K., Tilea, A., Stack, A. G., Balkrishnan, R., Yao, X., Noseworthy, P. A., Shah, N. D., Saran, R., & Nallamothu, B. K. (2018). Outcomes associated with apixaban use in patients with end-stage kidney disease and atrial fibrillation in the United States. Circulation, 138(15), 1519-1529. https://doi.org/10.1161/CIRCULATIONAHA.118.035418
Stanifer, J. W., Pokorney, S. D., Chertow, G. M., Hohnloser, S. H., Wojdyla, D. M., Garonzik, S., Byon, W., Hijazi, Z., Lopes, R. D., Alexander, J. H., Wallentin, L., & Granger, C. B. (2020). Apixaban versus warfarin in patients with atrial fibrillation and advanced chronic kidney disease. Circulation, 141(17), 1384-1392. https://doi.org/10.1161/CIRCULATIONAHA.119.044059
Reading the DNRS 6521 Week 4 instructions
For this week you typically receive or build a case in which two reasonable drug options exist and you must choose between them. The prompt asks you to state the criteria you will use, apply each to both options with evidence, reach a decision and explain the monitoring that follows. Many sections stress that either choice can score well if the reasoning is visible. Expect a four to six page APA 7 paper with current guidelines and trial evidence. Patient factors such as age, weight, kidney function and preferences should feed directly into the criteria. A short section on when the decision would be revisited is often required. Check whether your instructor wants a comparison table; a grid saves words when both options face identical criteria.
Inside the DNRS 6521 Week 4 example
Four pages that read as an argument rather than as a form. The composite presentation occupies half a page and includes the three factors that will decide the case, none of them flagged as decisive at that point. Both options then receive matched treatment across four criteria the writer names and justifies, and naming the criteria before applying them is what allows a reader to audit the outcome. A short paragraph identifies which single criterion carried the decision and concedes that a reasonable colleague weighting the criteria differently would land elsewhere. Monitoring and reassessment follow in a compact block. Eight references support the criterion claims rather than the background, and current guidance is cited as guidance rather than as instruction.
DNRS 6521 Week 4 rubric: what earns full marks
Documented reasoning is the criterion doing the most work, and it is the one writers most often assume they satisfied. A paper reaching a defensible selection without showing the weighing scores below a paper reaching a debatable selection that shows every step, which strikes many students as unfair until they mark a set themselves. Graders read the rejected option for signs of a straw comparison, and a losing option given three lines undermines the paper more than a weak criterion would. Guidance documents cited as authority rather than as evidence cost credit at doctoral level, where a rubric expects engagement rather than deference. Reassessment left off entirely is a common omission near a word ceiling. Balance across the two options is checked by length as well as by content.
Common DNRS 6521 Week 4 mistakes, and how to avoid them
The DNRS 6521 decision case most often loses marks by reaching a sensible choice without showing how the criteria led there. Name the criteria first and return to them by name. Another problem is relying on trials that excluded patients like yours; say when the evidence comes from a population with better kidney function. Students also apply standard dosing without checking the dose reduction rules, so state the dose and why. Do not dismiss the option you rejected in a sentence, since a fair comparison is part of the grade. Keep the creatinine, weight and age consistent, because the clearance has to be reproducible. Include the patient's view; preferences about monitoring are real criteria. Finish with clear reassessment triggers rather than a general call for follow-up.
Get a DNRS 6521 Week 4 example written to your instructions
Forward the decision prompt, the case, the rubric and any option set the classroom specified, and a paper that names its criteria before applying them comes back to you. The first custom one is free and turns around in 24 to 48 hours. Decisions already made for an actual patient are that patient's record and are not reconstructed on this desk.
More DNRS 6521 papers and DNP samples
- DNRS 6521 Week 1: Discussion Post
- DNRS 6521 Week 2: Case Write-Up
- DNRS 6521 Week 3: Pharmacogenomic Memo
- DNRS 6521 Week 5: Discussion Post
- DNRS 6521 Week 6: Interaction Analysis
- DNRS 6521 Week 7: Monitoring Plan
- DNRS 6521 Week 8: Prescribing Ethics Case
- DNRS 6521 Week 9: Formulary Review
- DNRS 6521 Week 10: Deprescribing Plan
- DNRS 6521 Week 11: QI Proposal
- NURS 6001 Week 4: Scholarly source screen
- DNRS 6501 Week 4: Evidence Appraisal
- NURS 6002 Week 4: MSN specialty choice rationale
- NURS 6914 Week 4: Family meeting writeup
DNRS 6521 Week 4 questions, answered
Can the paper choose either option and still score well?
In a well-built decision case, yes, because the assignment is testing the defense. Two writers reaching opposite selections can both land in the top band if each names criteria in advance and shows the weighing. What consistently loses points is a selection announced early and supported by evidence gathered afterward.
How many criteria are enough?
Four suits a case of this size and keeps each one properly applied. Two tends to leave the decision looking arbitrary, and seven produces a table nobody weighs. If the prompt in front of you names its own criteria, those replace the writer's, and the matched treatment shown in the example carries over without alteration.
Should current guidance be cited?
Yes, and the way it is cited matters at doctoral level. The example treats guidance as evidence with authorship and a date rather than as a rule to be followed, which is the register DNP rubrics expect. Deferring to a document without engaging its basis reads as undergraduate work even when the citation itself is flawless.
Where can I find a free DNRS 6521 Week 4 sample paper?
The warfarin versus apixaban decision case is reproduced in full here, with the criteria, both options, what carried the decision and the monitoring plan.
Can apixaban be used at a creatinine clearance of 22 in DNRS 6521 Week 4?
The example argues it can be used with care, noting that the major trials enrolled few such patients and that labeled dose reduction depends on age, weight and creatinine together.