Direct Oral Anticoagulant Use: A Practical Guide to Common Clinical Challenges

J Am Heart Assoc. 2020 Jul 7;9(13):e017559. doi: 10.1161/JAHA.120.017559. Epub 2020 Jun 15.


Direct oral anticoagulants (DOACs) have quickly become attractive alternatives to the long-standing standard of care in anticoagulation, vitamin K antagonist. DOACs are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOACs have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of DOACs, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of DOACs and act as a practical reference for clinicians to optimize DOAC use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.

Keywords: anticoagulation; oral direct thrombin inhibitor; oral factor Xa inhibitors; pharmacotherapy.

Publication types

  • Review

MeSH terms

  • Administration, Oral
  • Blood Coagulation / drug effects*
  • Clinical Decision-Making
  • Comorbidity
  • Cost-Benefit Analysis
  • Drug Costs
  • Drug Interactions
  • Drug Monitoring
  • Drug Substitution
  • Factor Xa Inhibitors / adverse effects
  • Factor Xa Inhibitors / economics
  • Factor Xa Inhibitors / pharmacokinetics
  • Factor Xa Inhibitors / therapeutic use*
  • Hemorrhage / chemically induced
  • Humans
  • Risk Assessment
  • Risk Factors
  • Treatment Outcome


  • Factor Xa Inhibitors