Navigating Oral Anticoagulants: Four Steps to Increase Safety

Every pharmacist in clinical practice will see patients who need or are taking anticoagulants; their use is almost ubiquitous among older adults.¹ Five oral anticoagulants (apixaban [Eliquis; Bristol Myers Squibb-Pfizer Alliance], dabigatran [Pradaxa; Boehringer Ingelheim], edoxaban [Savaysa; Daiichi Sankyo], rivaroxaban [Xarelto; Bayer-Janssen Pharmaceuticals], and warfarin [Coumadin; Bristol-Myers Squibb]) are available, and they have different levels of risk and adverse effects. Many organizations have implemented anticoagulation stewardship programs, similar to those used to manage antibiotic use, to minimize risk.

Anticoagulation management is multifaceted.^1,2 Table 1^1-3 lists the areas where pharmacists need to be involved in decision-making. Many experts now advocate for the use of 4 steps to ensure optimal oral anticoagulant use.^1-3

Table 1. Important Factors in Anticoagulation Management^1-3

Step 1: Maintaining Competencies With Updated Evidence

The multidisciplinary team involved in anticoagulation needs to embrace lifelong learning because the evidence related to anticoagulation evolves continuously.^4-7 That means watching for new guidelines, especially in atrial fibrillation, venous thromboembolism (VTE), and valvular disease, because these are the most common indications for anticoagulation.⁸ Evidence for decision-making should stem from general guidelines, situation-specific guidelines (eg, obesity or perioperative management), and the growing literature. Table 2 lists several free resources to keep up with the latest evidence.^4-7

Table 2. Resources to Maintain Anticoagulation Competencies^4-7

Pharmacists must take the lead in some areas. These include monitoring to ensure direct oral anticoagulant (DOAC) doses are correct, providing targeted warfarin monitoring, and managing special cases of patients taking concomitant antiplatelets.^1,9,10 When DOACs are used, pharmacists should focus on adherence to the prescribed dose and monitoring higher-risk situations like those that involve poor renal or hepatic function and extreme body weights. When prescribers use warfarin—many still prescribe it for patients who cannot afford the newer drugs, have been on warfarin for many years successfully, or have heart valves—watching food and drug interactions is critical. When appropriate, hematology, surgery, cardiology, pulmonology, and laboratory practitioners need to be involved in decisions regarding concomitant antiplatelet use.^1,9,10

Step 2: Leverage Technology

All organizations should use tools that can help mitigate errors and adverse events.^11-14 For example, most electronic medical records can incorporate pathways or guidelines and scoring calculators that help clinicians make decisions (but do not override clinical judgment). Quality and performance improvement departments are instrumental in conducting drug use reviews to identify areas of greatest risk. These areas often computerize best practice alerts and dashboards that can identify incorrect direct oral anticoagulation dosing, antiplatelet de-escalation opportunities, and VTE phase-of-care reminders.^11-14

Step 3: Establish Shared Responsibility

Patients have an inherent risk of bleeding because they are on anticoagulants; they need to appreciate the risk. Staff and patients—and their families and caregivers—need to collaborate to ensure that anticoagulation will be safe and effective.^3,15 Initially, they need face-to-face education with several health care professionals who provide redundant, consistent education. Education needs to be ongoing, tailored to the patient’s needs, and clearly explained, especially if an interpreter is needed. Delivering education in writing, using teach-back methods, and including both clinical and logistical information are prudent.^3,15

Tips for best counseling include assessing baseline education using open-ended questions such as the following⁸:

• What did they tell you this medication is for?
• How did they tell you to take this?
• What did they tell you to watch out for?

Subsequently, pharmacists can fill in gaps using short, simple language tailored to a patient’s health care literacy and can incorporate culturally sensitive information into patient education. Finally, a key and often-overlooked step following education is documentation. It’s critical to document the patient’s understanding.⁸

Step 4: Focus on Transitions of Care

In transitions of care (TOC), the pharmacy team has significant responsibilities. Unfortunately, almost all patients may experience medication discrepancies as they transition between phases of care.^16,17 Pharmacy teams are vital to minimizing preventable medication discrepancies, especially for high-risk medications such as anticoagulants. TOC errors can occur during the initiation of anticoagulation, the highest-risk period of management. This can be due to incorrect dosing, inappropriate drug selection, and drug acquisition challenges. Unintended errors may also occur as patients transition between anticoagulants during hospitalization or after procedures. Prescribers may even omit a home anticoagulant on discharge in error.^16,17

Pharmacy teams need to conduct very high-quality medication reconciliation because failure to do so can result in errors that lead to preventable hospital readmissions. Often, this means acting like a detective and making a few or even many calls to members of the multidisciplinary team to determine whether a change is unintended and accidental or intentional.^16,17

Conclusion

Keeping up, paying attention to alerts, educating thoroughly, and taking TOC monitoring seriously are 4 ways to steward oral anticoagulant use well. Many tools are available to help. Using them is simple—and often free.

REFERENCES

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2. Budnitz DS, Shehab N, Lovegrove MC, Geller AI, Lind JN, Pollock DA. US emergency department visits attributed to medication harms, 2017-2019. JAMA. 2021;326(13):1299-1309. doi:10.1001/jama.2021.13844

3. National patient safety goals. The Joint Commission. Accessed March 15, 2025. https://www.jointcommission.org/en-us/standards/national-patient-safety-goals

4. Guidelines and topic collections. American College of Chest Physicians. Accessed January 1, 2026. https://www.chestnet.org/guidelines-and-topic-collections

5. Resource center. Anticoagulation Forum. Accessed January 1, 2026. https://acforum.org/web/resource-center.php

6. Anticoagulation desktop reference (version 2.6). Michigan Anticoagulation Quality Improvement Initiative. Updated January 26, 2022. Accessed January 1, 2026. https://anticoagulationtoolkit.org/sites/default/files/toolkit_pdfs/toolkitfull_2.6.pdf

7. ASH Clinical Practice Guidelines on venous thromboembolism. American Society of Hematology. Accessed January 1, 2026. https://www.hematology.org/education/clinicians/guidelines-and-quality-care/clinical-practice-guidelines/venous-thromboembolism-guidelines/ash-guidelines-on-use-of-anticoagulation-in-patients-with-covid-19

8. Anticoagulation management pearls 2025 revision. University of Connecticut School of Pharmacy. Accessed January 1, 2026. https://pharmacy.uconn.edu/course/anticoagulation-management-pearls2025/

9. Joglar JA, Chung MK, Armbruster AL, et al; Peer Review Committee Members. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193

10. Rao SV, O’Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;151(13):e771-e862. doi:10.1161/CIR.0000000000001309

11. Advancing anticoagulation stewardship: a playbook. National Quality Forum and Anticoagulation Forum. Accessed January 1, 2026. https://acforum-excellence.org/Resource-Center/resource_files/1977-2022-08-24-063128.pdf

12. Triller DM, Wilson AS, Allen AL, et al. Digital dashboards for direct oral anticoagulant surveillance, intervention and operational efficiency: uptake, obstacles, and opportunities. J Thromb Thrombolysis. 2024;57(1):107-116. doi:10.1007/s11239-023-02893-9

13. Triller DM, Wilson AS, Allen AL, et al. Digital dashboards for direct oral anticoagulant surveillance, intervention and operational efficiency: uptake, obstacles, and opportunities. J Thromb Thrombolysis. 2024;57(1):107-116. doi:10.1007/s11239-023-02893-9

14. Valencia D, Spoutz P, Stoppi J, et al. Impact of a direct oral anticoagulant population management tool on anticoagulation therapy monitoring in clinical practice. Ann Pharmacother. 2019;53(8):806-811. doi:10.1177/1060028019835843

15. Snyder DJ, Zilinyi RS, Cohen DJ, Parikh SA, Sethi SS. Patient-reported outcomes in venous thromboembolism: a systematic review of the literature, current challenges, and ways forward. J Am Heart Assoc. 2023;12(23):e032146. doi:10.1161/JAHA.123.032146

16. Amin A, Marrs JC. Direct oral anticoagulants for the management of thromboembolic disorders: the importance of adherence and persistence in achieving beneficial outcomes. Clin Appl Thromb Hemost. 2016;22(7):605-616. doi:10.1177/1076029615601492

17. Transition of anticoagulants 2019. 2019. Accessed January 1, 2026. https://acforum-excellence.org/Resource-Center/resource_files/1322-2019-03-08-101259.pdf