Abstract
Background There is an increasing amount of literature on direct oral anticoagulant (DOAC) laboratory
monitoring. The aims of the present review were to evaluate published data on monitoring
DOACs, to provide clinical guidance on how to interpret results, and to summarize
why, when, and how to monitor DOACs.
Methods The publications screened for this review were obtained through a PubMed search for
articles published in English or French before April 2019 that had the following as
their main themes: DOAC monitoring, DOAC exposure–effect relationship, DOAC drug interactions,
and pharmacokinetics and pharmacodynamics of DOACs.
Results DOACs show important inter- and intrapersonal concentration variability and a significant
exposure–effect relationship. Concentrations out of the expected range have been shown
to lead to an increased adverse event rate and a lower efficacy. No definitive therapeutic
range exists for DOACs except for dabigatran for which trough levels of 40 to 200 ng/mL
seem to be the consensus. Indications to monitor include suspected drug accumulation
in special patient populations, suspected drug failure, and acute situations such
as hemorrhagic or thrombotic events.
Conclusion There is a likely benefit to monitor DOACs in order to improve their safety and efficacy
but randomized controlled trials are required to determine the therapeutic range of
these drugs and evaluate whether DOAC monitoring can improve outcomes in a clinical
setting.
Keywords
direct oral anticoagulant - monitoring - dose tailoring - plasma level
