MHRA advice for all DOACs:

  • MHRA advice: Direct-acting oral anticoagulants (DOACs): reminder of dose adjustments in patients with renal impairment (May 2023) (www.gov.uk).
  • MHRA advice: Warfarin and other anticoagulants: monitoring of patients during the COVID-19 pandemic (October 2020) (www.gov.uk).
  • MHRA advice: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents (June 2020) (www.gov.uk).
  • MHRA advice: Direct-acting oral anticoagulants (DOACs): increased risk of recurrent thrombotic events in patients with antiphospholipid syndrome (June 2019) (www.gov.uk).
  • MHRA advice: New oral anticoagulants apixaban (Eliquis®), dabigatran (Pradaxa®) and rivaroxaban (Xarelto®) - cautions and contra-indications (December 2014) (www.gov.uk).

Guidelines:

Notes: 

  • NHS Highland have developed a DOAC counselling tool (NHS Highland intranet access required) to standardise the information given to patients prescribed DOACs.  This tool is to be used by pharmacists, pharmacy technicians, doctors and advanced nurse practitioners involved in the prescribing and dispensing of DOACs.  Please document in the patient's record when counselling has been performed.
  • If DOAC is contra-indicated: low molecular weight heparin (LMWH) overlapping with warfarin, is the alternative treatment, 
  • If both choices are contra-indicated, then discuss further options with the Haematology Department.
  • Active cancer; patients receiving treatment for cancer within the previous 6 months or currently receiving palliative treatment should be treated with LMWH, for at least the first 6 months of therapy. If treatment for longer than 6 months is required, it may be appropriate to switch to an alternative anticoagulant. Discuss with Haematology.

APIXABAN - (First line)

Therapy notes

Formulation and dosage details

Formulation:

Tablets 2·5mg, 5mg

Dosage:

  • Prophylaxis of stroke and systemic embolism in non-valvular atrial fibrillation and at least one risk factor, eg, previous stroke or transient ischaemic attack, symptomatic heart failure, diabetes, hypertension, or age (75 years and over)
  • Prophylaxis of venous thromboembolism following knee replacement surgery
  • Prophylaxis of venous thromboembolism following hip replacement surgery
  • Treatment of deep-vein thrombosis, treatment of pulmonary embolism
  • Prophylaxis of recurrent deep-vein thrombosis, prophylaxis of recurrent pulmonary embolism.

EDOXABAN - (Second line)

Therapy notes

Formulation and dosage details

Formulation:

Tablets 15mg, 30mg, 60mg

Dosage:

  • Prophylaxis of stroke and systemic embolism in non-valvular atrial fibrillation, in patients with at least one risk factor (such as congestive heart failure, hypertension, aged 75 years and over, diabetes mellitus, previous stroke or transient ischaemic attack)
  • Treatment of deep-vein thrombosis
  • Prophylaxis of recurrent deep-vein thrombosis
  • Treatment of pulmonary embolism
  • Prophylaxis of recurrent pulmonary embolism.

DABIGATRAN - (Second line)

Therapy notes

Formulation and dosage details

Formulation:

Capsules 110mg, 150mg

  • Patient must be able to swallow capsule whole, as opening or chewing the capsule increases oral bioavailability and bleeding risk.
  • Unsuitable for storage in monitored dosage systems (MDS).

Dosage:

  • Prophylaxis of stroke and systemic embolism in non-valvular atrial fibrillation and with one or more risk factors such as previous stroke or transient ischaemic attack, symptomatic heart failure, age ≥ 75 years, diabetes mellitus, or hypertension
  • Prophylaxis of venous thromboembolism following total knee replacement surgery
  • Prophylaxis of venous thromboembolism following total hip replacement surgery
  • Treatment of deep-vein thrombosis
  • Treatment of pulmonary embolism
  • Prophylaxis of recurrent deep-vein thrombosis
  • Prophylaxis of recurrent pulmonary embolism.

RIVAROXABAN - (Second line)

Therapy notes

  • MHRA advice: After transcatheter aortic valve replacement: increase in all-cause mortality, thromboembolic and bleeding events in a clinical trial (October 2018) (www.gov.uk).
  • MHRA advice: Rivaroxaban (Xarelto): reminder that 15mg and 20mg tablets should be taken with food (July 2019) (www.gov.uk).

Formulation and dosage details

Formulation:

Tablets 10mg, 15mg, 20mg

  • To be taken with food.

Dosage:

  • Prophylaxis of stroke and systemic embolism in patients with non-valvular atrial fibrillation and with at least one of the following risk factors: congestive heart failure, hypertension, previous stroke or transient ischaemic attack, age ≥ 75 years, or diabetes mellitus
  • Prophylaxis of venous thromboembolism following knee replacement surgery
  • Prophylaxis of venous thromboembolism following hip replacement surgery
  • Treatment of deep-vein thrombosis
  • Treatment of pulmonary embolism
  • Prophylaxis of recurrent deep-vein thrombosis
  • Prophylaxis of recurrent pulmonary embolism
  • Multiple myeloma to counteract the prothrombotic effect of immune modulating drugs (specialist haematology use only) off-label, 10mg once daily

Formulation and dosage details

Formulation:

Tablets 2∙5mg (specialist initiation only as per CAD/PAD guideline)

Dosage:

  • Prophylaxis of atherothrombotic events following an acute coronary syndrome with elevated cardiac biomarkers (in combination with aspirin alone or aspirin and clopidogrel)
  • Prophylaxis of atherothrombotic events in patients with coronary artery disease or symptomatic peripheral artery disease at high risk of ischaemic events (in combination with aspirin).

Guideline:

CAD/PAD guideline

WARFARIN - (Third line)

Therapy notes

  • MHRA advice: Warfarin: be alert to the risk of drug interactions with tramadol (June 2024) (www.gov.uk)
  • MHRA advice: Direct-acting antivirals to treat chronic hepatitis C: risk of interaction with vitamin K antagonists and changes in INR (January 2017) (www.gov.uk)
  • MHRA advice: Warfarin: reports of calciphylaxis (July 2016) (www.gov.uk)

Formulation and dosage details

Formulation:

Tablets 500 micrograms, 1mg, 3mg

Dosage:

  • Prophylaxis of embolisation in rheumatic heart disease and atrial fibrillation
  • Prophylaxis after insertion of prosthetic heart valve
  • Prophylaxis and treatment of venous thrombosis and pulmonary embolism
  • Transient ischaemic attacks.

Refer to BNF for contraindications or complications.

  • There is a wide range of drug and dietary interactions with warfarin which should be carefully considered, refer to BNF.
  • Where antibiotics are required, note that many antibiotics interact with warfarin. Ideally patients should be advised and the INR should be checked at baseline and rechecked three days after starting a course of antibiotics, regardless of the length of the antibiotic course.
  • On discharge from hospital, to ensure that anticoagulant monitoring can be provided safely, information on the anticipated duration of anticoagulation, target INR, indication and current dose of warfarin must be provided. This information is contained in a form within the Immediate Discharge Document (IDD) system, eg IDL, and should be emailed to whoever is responsible for the ongoing management of the patient’s anticoagulation.

Guidance:

Formulation and dosage details

Formulation:

Tablets 5mg (Non-Formulary, not recommended)

No longer recommended for the general population to avoid confusion with the 500 microgram (0·5mg) tablet. There may however be some patients whose risk/benefit is to continue to use the 5mg tablet.

Editorial Information

Last reviewed: 25/04/2024

Next review date: 30/04/2027

Version: 2

Approved By: TAMSG of the ADTC

Document Id: F022