DOAC - Monitoring


Why this page is important: One of the advantages of the DOACs is that they do not need routine anticoagulation monitoring (INR tests are unreliable). First you need to determine your patient's renal function then follow the table bellow to decide how ften to monitor and follow the checklist at every review.

 Blood test

Patient characteristics Recommended monitoring

CrCl > 60ml/min

Annual U&E FBC and LFTs

CrCl between 30-60ml/min and/or aged >75 years and/or frail

6 monthly U&E FBC and LFTs

CrCl 15-30ml/min 3 monthly U&E FBC and LFTs & check for side effects/bleeding issues and patient adherence to therapy at each routine appointment



Assessment Recommendation
Assess compliance Review prescribing schedule, calculate and document average adherence If patient has stopped taking DOAC, establish whether this was secondary to side-effects, accidental stoppage, temporary /permanent cessation by another clinician. Re-educate on importance of strict intake schedule Inform about compliance aids (e.g. dossette box, blister pack, reminder charts, smartphone applications) NOTE: Dabigatran must remain in original packaging
Assess for thrombotic complications History of stroke/TIA, DVT/PE in last treatment interval
Assess for other side-effects

Dyspepsia common with dabigatran; consider PPI or alternative agent Other side effects: Review dose? Switch to alternative agent?

NB: DOACs are ‘black triangle’ drugs – All adverse drug events must be reported to MHRA via

Assess risk versus benefit of anticoagulation and decide whether ongoing anticoagulation is still appropriate.

For example, can anticoagulant therapy be stopped in patients with prior DVT / PE, where the risk of recurrence is now considered low – seek specialist advice if necessary

Has their bleed risk increased

Ensure that current dose of DOAC is still optimal in light of age, weight and renal function, liver function etc.
  • See guidance on DOAC dosing
  • avoid use of DOACs if <CrCL 30 mL/min (dabigatran contraindicated)
  • If edoxaban is used for AF, review choice of agent if CrCL >95mL/min as efficacy is reduced)
  • avoid if weight is ​<50kg or >120kg.


Review concurrent medication, including over the counter medication, herbal remedies  THERE WILL BE A LINK HERE TO THAT PAGE
Repeat HASBLED score

≥3 means at increased bleeding risk

  • Correct potentially reversible risk factors
  • Ensure more frequent reviews are in place
  • Check for any bleeding episodes “nuisance bleeding’ – are preventative measures possible?
  • Reinforce importance of carrying ‘patient alert’ card at all times
Assess for bleeding complications
  • Persistent nausea, stomach upset, or vomiting blood or other material that looks like coffee grounds
  • Headaches, dizziness, or weaknes
  • Nosebleeds
  • Dark red or brown urine
  • Blood in the bowel movement or dark-colored stool

 Treatment should be stopped if severe bleeding occurs

see managing bleeding complications




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