DOACs have made blood thinning simpler for millions of people: no routine INR checks and fewer food interactions. But they still need to be taken carefully, because missed doses raise clot risk and bleeding can be serious.
Imagine being diagnosed with atrial fibrillation and started on apixaban to prevent a stroke. Your neighbour on warfarin goes for blood tests every few weeks; you do not. Does that mean your medicine is less serious? Not at all.
What DOACs are
Direct oral anticoagulants (DOACs), also called NOACs, are blood thinners that work by directly blocking specific clotting factors. They include apixaban, rivaroxaban and edoxaban, which block factor Xa, and dabigatran, which blocks thrombin.,They are used instead of warfarin for many people because they work quickly, have fewer food interactions and do not need routine INR monitoring.
Why they are prescribed
- To reduce the risk of stroke in atrial fibrillation
- To treat deep vein thrombosis (DVT) and pulmonary embolism (PE)
- To prevent clots after hip or knee replacement surgery
- To prevent clots coming back after a DVT or PE
Who may not be able to take them
- People with mechanical heart valves, who need warfarin
- People with certain types of valve disease
- Some people with severe kidney or liver disease
- People with antiphospholipid syndrome, in many cases
- During pregnancy and breastfeeding, where other treatments are usually used
Taking your DOAC correctly
- Take it at the same time(s) each day; apixaban and dabigatran are usually twice daily, rivaroxaban and edoxaban usually once daily
- Some doses of rivaroxaban should be taken with food; check your instructions
- Do not stop without talking to your healthcare provider, even if you feel well
- Keep a supply so you do not run out
If you miss a dose
Rules differ between DOACs. As a general guide, for twice-daily DOACs, take a missed dose if you remember within about six hours; otherwise skip it. For once-daily DOACs, take it if you remember within about 12 hours; otherwise skip it. Never take a double dose. Check the leaflet for your specific medicine or ask your pharmacist.
Signs of bleeding to watch for
- Bruising more easily, or bleeding gums
- Nosebleeds lasting more than 10 minutes
- Blood in urine, or red or black, tarry stools
- Coughing or vomiting blood
- Heavy or prolonged periods
- Severe headache, especially after a fall or head injury
- Seek urgent help for heavy bleeding, a head injury or signs of internal bleeding
Interactions
DOACs interact with fewer medicines than warfarin, but some interactions are important. Anti-inflammatory painkillers such as ibuprofen and aspirin increase bleeding risk. Some antifungal, antiviral, anti-epilepsy and antibiotic medicines can raise or lower DOAC levels. St John’s wort can reduce their effect.,Always tell every healthcare provider, dentist and pharmacist that you take a DOAC before starting any new medicine.
Kidney function
Most DOACs are partly removed by the kidneys. Your healthcare provider will check kidney function before starting and regularly afterwards, often yearly or more often in older adults, because the dose may need to change if kidney function falls.
Before surgery, dental work or procedures
Tell the team you take a DOAC well in advance. For minor dental work, it is often continued or only a dose is delayed. For larger procedures, it may be paused for one to several days, depending on the DOAC, the procedure and your kidney function. Do not stop on your own; follow the plan you are given.
Reversal in emergencies
Specific reversal agents exist for some DOACs, such as idarucizumab for dabigatran and andexanet alfa for factor Xa inhibitors, though availability varies. Carrying an anticoagulant alert card helps emergency teams treat you quickly.
Living well on a DOAC
- Carry an anticoagulant alert card or wear medical ID
- Take extra care to prevent falls and injuries
- Use a soft toothbrush and electric razor if you bruise or bleed easily
- Keep alcohol moderate
- Attend regular medicine reviews
Frequently asked questions
Do I need blood tests?
Not to measure clotting routinely, but kidney function, blood count and liver tests are checked regularly.
Can I take paracetamol?
Paracetamol is usually the preferred painkiller. Avoid anti-inflammatories unless advised.
Is a DOAC better than warfarin?
For many people, DOACs are as effective with lower risk of brain bleeding, but warfarin is still best for some conditions.
But I feel fine. Can I stop?
Feeling fine does not mean your clot or stroke risk has gone. Stopping without advice can lead to a stroke or clot. Talk to your healthcare provider first.
Your next step: Set a daily phone reminder for your DOAC doses and keep your alert card in your wallet.
Related: Atrial fibrillation
Sources: European Heart Rhythm Association practical guide on DOACs, National Institute for Health and Care Excellence, British National Formulary (BNF), American Heart Association.
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