DOAC dosing and monitoring: the gaps a healthcheck usually finds

Direct oral anticoagulants are now familiar medicines in primary care, but familiarity can hide gaps. A prescription may look unchanged while the patient's renal function, weight, other medicines or circumstances have moved on. A healthcheck brings these changes into view. The aim is not simply to count overdue blood tests: it is to establish who is taking a DOAC, whether the prescription remains appropriate and who will keep the monitoring cycle running.

1. Start with an accurate register

A register built only from diagnosis codes can miss patients whose anticoagulant was started elsewhere or recorded inconsistently. It can also include people whose treatment has stopped. Search prescribing records for apixaban, rivaroxaban, edoxaban and dabigatran, including relevant brand names, then reconcile the results with current medication lists and recent hospital correspondence. Confirm the indication, intended duration and responsible prescriber for each patient. Record unresolved discrepancies as actions rather than assuming that an old entry is correct.

2. Check the dose against current information

DOAC dose rules differ between medicines and indications. A dose that was correct at initiation may no longer fit the patient. Check the current indication, age, weight and renal function against the medicine's current product information and national guidance. For DOAC dosing, assess renal function using Cockcroft–Gault creatinine clearance where recommended, rather than substituting the laboratory's eGFR. Ensure the weight used is recent and clinically appropriate, and document the calculation and decision.

Missing measurements make a dose unverified, not automatically incorrect. Arrange the information needed and prioritise clinical review according to risk. Do not apply one medicine's dose reduction criteria to another. A pharmacist independent prescriber should assess any proposed change within agreed procedures, involving the patient and escalating complex or uncertain cases to the responsible GP or specialist.

3. Review interacting medicines

The repeat list is only part of the interaction picture. Check recent acute prescriptions, hospital changes, over-the-counter medicines and supplements. Antiplatelets and non-steroidal anti-inflammatory drugs can increase bleeding risk, while other medicines can alter DOAC exposure. Use an up-to-date interaction reference and the relevant product information. Confirm why combinations are being used and whether a specialist has specified a duration. Resolve unclear plans with the prescriber; do not stop an essential medicine solely because a search flags it.

4. Turn overdue monitoring into completed actions

A date on a recall list does not show that monitoring happened. Identify missing or overdue renal function, full blood count and liver function checks, then set an individual review interval using current guidance and clinical judgement. Stable patients generally need at least annual review, with more frequent assessment when renal function is impaired, frailty is present or an intercurrent illness could change risk. Check that results have been reviewed and acted on, not merely filed.

Use a closed-loop process: invite the patient, track attendance, chase missing results and assign abnormal findings to a clinician. Agree what happens after non-attendance, including direct contact and a documented prescribing decision. An overdue test should trigger assessment, not an automatic interruption of anticoagulation that could expose the patient to harm.

5. Give recall a named owner

Monitoring often slips because each task belongs to a different team and nobody owns the whole pathway. Name a clinical lead and an operational recall owner, with cover arrangements. Their shared process should specify who refreshes the register, sends invitations, reviews results, adjusts recall dates and follows unresolved actions. Review an exception list regularly so patients who have not completed monitoring remain visible.

Leave a system, not just a report

A useful healthcheck ends with a prioritised action list, documented patient reviews and a repeatable monitoring process. Keep the searches, templates and standard operating procedure together, train the people using them and agree when the cohort will be checked again. That turns a one-off audit into a safer prescribing pathway with clear responsibility for what happens next.