Selecting the correct anticoagulation and ensuring this is prescribed and maintained at the correct dose is essential to realise the benefits of treatment while minimising risks. Each DOAC has a standard dose and a reduced dose.

The criteria for dose reduction varies between drugs. Dose reductions depend on factors such as age, weight, renal function and concomitant medication. Selection of dose for any individual patient should reflect that in the manufacturer’s product licence.

For patients where time in therapeutic range with warfarin is sub-optimal (less than 65 per cent), a switch to a DOAC could be considered. It should be noted that poor adherence to warfarin is not necessarily a reason to switch unless the reason for poor adherence is tackled at the same time.

In order to switch safely, a current INR is needed. Refer to the advice from the manufacturer on how to switch to an individual DOAC. The combination of anticoagulation and antiplatelet therapy significantly increases bleeding risk. In many cases, the antiplatelet can be stopped when anticoagulation is introduced, so this combination should always be clarified to ensure it is intentional.