MICA · FIRST-LINE LEARNING NOTES
Understand, prioritise and organise follow-up
Anticoagulant follow-up checks thrombotic protection and bleeding risk together. The absence of routine INR monitoring for a DOAC does not remove the need for clinical and laboratory review.
Reconfirm the indication
Record indication, timing of the event, intended duration and coordinating prescriber. Atrial fibrillation, venous thromboembolism and specialist indications require different regimens. In atrial fibrillation, assess thromboembolic risk and modifiable bleeding factors using the chosen guideline. Bleeding scores help address risks and plan review.
[1]Check the actual prescription
Check the agent, indication, prescribed regimen, weight, kidney and liver function and other medicines. For DOAC dosing, use the renal estimate required by the product; Cockcroft–Gault creatinine clearance is usually needed. Do not automatically substitute the laboratory eGFR. An unsupported empirical dose reduction may reduce antithrombotic protection.
[2][3]DOAC treatment still requires review of adherence, bleeding, renal function and interactions. INR is not used to adjust DOAC doses as it is for vitamin K antagonists. Falling haemoglobin without visible bleeding requires consideration of occult blood loss. Treatment schedules also depend on indication and the phase of therapy.
[2][3]Plan higher-risk situations
Review NSAIDs, antiplatelets, interacting medicines and self-medication. Provide written information or an anticoagulant alert card. Procedures, bleeding, missed doses and new medicines require product-specific advice and clinical context. Interruption, resumption and any bridging depend on several risks; patients should not improvise these decisions from a general rule.
[3][2]- Check antiplatelets, NSAIDs and non-prescription products before adding treatment.
- Major bleeding, head injury or neurological symptoms requires urgent assessment with the last dose time communicated.
- Coordinate bridging, perioperative interruption and resumption after complex bleeding with the appropriate specialist team.
Monitor clinically and with relevant tests
For vitamin K antagonists, organise INR testing and communication. For DOACs, review blood count, kidney and liver function according to risk. Bring review forward during acute illness, dehydration or a new interaction. Look for bleeding, anaemia, adherence difficulties and access barriers. Major bleeding, neurological deficits or head injury while anticoagulated require urgent assessment.
[2][3][4]A learning situation
FICTIONAL CASE · SELF-REFLECTION WITHOUT A SCORE
A patient taking a DOAC for atrial fibrillation reports prolonged diarrhoea, increased creatinine and recent ibuprofen use for toothache. There is no visible bleeding. They assume no review is needed because they never require INR testing.
What review is needed?
Read the reasoning
Prompt review of bleeding risk, kidney function and concomitant medicines is required. No INR requirement does not guarantee appropriate drug exposure or stable renal function. The clinician checks product criteria and determines management; any adjustment is agreed with the prescriber according to progress and product criteria.
References and scope
- Atrial fibrillation: diagnosis and management — Recommendations ↗
- DOACs (Direct Oral Anticoagulants) monitoring ↗
- Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents ↗
- Anticoagulant medicines — Side effects ↗
Original educational synthesis for adult first-line practice. International references must be interpreted with the clinical setting and local care pathways. Independent human scientific review remains to be confirmed.