Optimisation of direct-acting oral anticoagulants (DOACs) use for atrial fibrillation (AF) and venous thromboembolism: a practical guide.

INTRODUCTION: Direct oral anticoagulants (DOACs) are preferred as the first line oral anticoagulation therapy for atrial fibrillation and venous thromboembolism, given their superior efficacy and safety profile over vitamin K antagonists (VKAs). However, it can be challenging to select the optimal agent, dose or strategy in many clinical situations.

AREAS COVERED: This narrative review summarizes the current recommendations for optimization of DOAC therapy and attempts to shed light from recent evidence where there is clinical uncertainty. Particular focus is given to patients with renal impairment or supranormal renal function, those at extremes of body weight and those with high bleeding risk. Also discussed is the conundrum of timing of anticoagulant reinitiation after major hemorrhage or ischemic stroke.

EXPERT OPINION: DOAC use has expanded substantially since their introduction almost two decades ago. This is partially due to increased clinician familiarity with their use. However, simultaneous evidence has grown supporting their effectiveness in a wider range of patients, including patients with very high or very low body weight, as well as patients on regular hemodialysis. A greater awareness of these developments will allow more patients to benefit from the advantages of DOACs over other agents.