Abstract
The direct oral anticoagulants (DOACs) have quickly become popular choices for convenient stroke and thromboembolism protection. Popularity of this new anticoagulant class is driven by their predictable fixed dosing without the necessity for serum monitoring of anticoagulant effect. However, this convenience must be balanced against the risk of gastrointestinal (GI) bleeding. Age >65 years, hepatorenal dysfunction, low body weight, concomitant prescription of antiplatelet agents, or non-steroidal anti-inflammatory drugs, and drugs that interact with P-glycoprotein or the cytochrome P450 system, can influence therapeutic effectiveness of DOACs and increase the risk of GI bleeding. In this state-of-the-science review, these aforementioned risks are explored, as is DOAC pharmacology and the potential for drug, dietary, and herbal supplement interaction. Current best practice recommendations for peri-endoscopic DOAC management and temporary interruption are reviewed. The utility of existing risk-prediction scores and other practical risk-management strategies, based on specific patient characteristics, are highlighted. Finally, pragmatic advice to enhance GI and cardiology dialogue, patient education, and shared decision-making regarding DOAC prescription is provided.
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