When Are Direct-Acting Oral Anticoagulants Not the Standard of Care?

For most patients who require anticoagulation, direct-acting oral anticoagulants (DOACs) have so many advantages compared with warfarin that clinicians often no longer think about initiating warfarin. This shift in practice during the past decade certainly makes sense for anticoagulation in patients with venous thromboembolism or atrial fibrillation: Multiple large, randomized trials have confirmed that outcomes are equivalent or better with DOACs than with warfarin for those two indications — and DOAC therapy is much easier to manage.

However, for various other clinical conditions, the data supporting DOACs (instead of warfarin or antiplatelet therapy) are less compelling. Recently, a group of experts published a comprehensive, but very rea…