Direct Oral Anticoagulants

Direct Thrombin Inhibitors: Dabigatran

Inhibit thrombin generation, preventing the development of a clot

Direct Xa inhibitors: Apixaban, Edoxaban, and Rivaroxaban

Inhibit factor Xa which inhibits thrombin generation and prevents the development of a clot

Stopping DOAC

• Idarucizumab is now available as an antidote for Dabigatran (on Specialist advice only)
• Andexanet Alfa is an antidote for Apixaban and Rivaroxaban (on Specialist advice only)
• If severe bleeding occurs, treatment should be stopped immediately. DOACs have a relatively short duration.
• DOACs should be stopped prior to invasive procedures/surgery

Concomitant use of DOACs with medicines that affect haemostasis may increase the risk of bleeding e.g. Aspirin, NSAIDs SSRIs, and SNRIs

Monitor renal function at baseline and for older adults at least annually. The dose adjustments recommended in renal impairment for all DOACS are based on the CrCI not the eGFR

Concomitant treatment with any other anticoagulants is contraindicated except when switching from a DOAC to Warfarin

DOACs and parental anticoagulants should never be prescribed concomitantly.

DOACs in extremes of body weight

Guidance from the SSC of the ISTH

For patietns with BMI > 40 or weight > 120 kg - a standard dose rivaroxaban or apixaban are appropriate anticoagulant options. The guidelines recommended not to regularly follow peak or trough drug-specific DOAC levels, because there is insufficient data to influence management decisions.