Practical Prescribing: Direct oral anticoagulants
BMJ 2024; 386 doi: https://doi.org/10.1136/bmj-2024-079520 (Published 30 August 2024) Cite this as: BMJ 2024;386:e079520
- Roy Khalife, haematologist, assistant professor of medicine1,
- Allison E Burnett, antithrombosis stewardship pharmacist, associate clinical professor2,
- Tobias Tritschler, internist, scientist3,
- Beth Waldron, independent patient advocate and patient author4,
- Yan Xu, haematologist, assistant professor of medicine1
- 1Department of Medicine (Hematology), The Ottawa Hospital, University of Ottawa, Ottawa, Canada
- 2University of New Mexico Hospital, UNM College of Pharmacy, Albuquerque, NM, USA
- 3Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- 4Patient author, Chapel Hill, NC
- Correspondence to R Khalife rkhalife{at}toh.ca
Practical Prescribing is a series produced in conjunction with the Drug and Therapeutics Bulletin to highlight important issues for prescribers to consider and prompts for shared decision making between prescribers, patients, and their carers. Targeted at all medical and non-medical prescribers, particularly doctors in training, the series covers medicines commonly prescribed in primary and secondary care.
What you need to know
Dosing and duration of direct oral anticoagulant (DOAC) treatments vary based on their indication, as well as a patient’s weight and renal function
Before initiating treatment, assess baseline haemoglobin and platelet levels, check renal and liver function, and calculate creatinine clearance
Bleeding events are a common complication; educate patients on recognising symptoms, including coffee ground vomit, coloured urine, and severe or persistent dizziness
A 75 year old man with hypertension and severe knee osteoarthritis presented to the emergency department after a mechanical fall complicated by a radial head fracture that was managed conservatively. Prior to admission, he was being treated with ramipril and metoprolol, and was using as-needed over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis. Non-valvular atrial fibrillation was diagnosed in the emergency department, warranting ongoing management. After reviewing local stroke prevention guidelines, you would like to prescribe a direct oral anticoagulant (DOAC). He asks you why he needs another medication in addition to all the others he takes.
How often are direct oral anticoagulants prescribed and how do they work?
Vitamin K antagonists were previously the standard treatment for oral anticoagulation, but in the past decade DOACs have superseded them because of their superior safety profile,1 ease of use, fewer monitoring requirements, and minimal food and drug interactions.2 An extended study of drug usage across six European nations found increased prescriptions of DOACs in non-valvular atrial fibrillation between 2008 and 2015.3 In England, apixaban, rivaroxaban, and edoxaban rank in the top 10 for prescription items dispensed in the community.4 In the …
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