Inappropriate prescriptions of direct oral anticoagulants (DOACs) in hospitalized patients: A narrative review

Thromb Res. 2023 Nov:231:135-140. doi: 10.1016/j.thromres.2023.03.007. Epub 2023 Mar 27.


Direct oral anticoagulants (DOACs) have become the cornerstone for prevention of thromboembolic events in patients with atrial fibrillation and patients with a history of venous thromboembolism. However, studies show that DOAC prescriptions are commonly inconsistent with guideline recommendations. DOAC dosing in the acutely ill patient could impose an even greater challenge. In this review, we describe the prevalence of inappropriate inpatient prescribing of DOACs and the associated rationales, predictors and clinical consequences. With the aim of promoting appropriate prescriptions of DOACs to hospitalized patients, we further outline DOAC dose reduction criteria justified by various guidelines, illustrating the complexities of appropriate dosing, especially in acutely ill patients. Moreover, we will discuss the impact of anticoagulant stewardship programs and the vital role that pharmacists may play in optimizing inpatient DOAC treatment.

Keywords: Anticoagulants; Atrial fibrillation; DOAC; Direct oral anticoagulant; Guideline adherence; Inappropriate prescribing; Inpatients; Offlabel use; Venous thromboembolism.

Publication types

  • Review

MeSH terms

  • Administration, Oral
  • Anticoagulants / adverse effects
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / drug therapy
  • Atrial Fibrillation* / epidemiology
  • Humans
  • Inappropriate Prescribing
  • Retrospective Studies
  • Rivaroxaban / therapeutic use
  • Stroke* / drug therapy
  • Venous Thromboembolism* / complications


  • Rivaroxaban
  • Anticoagulants