cardiology

DOAC Score for Selecting Direct Oral Anticoagulant in Non-Valvular AF

Practical scoring tool to guide DOAC selection over warfarin in patients with non-valvular atrial fibrillation. Considers renal function, drug interactions, adherence, and patient-specific factors.

Used in: Atrial Fibrillation

Score interpretation

Standard DOAC Candidate -- Any DOAC Suitable 0–1

No major modifying factors -- any DOAC is appropriate based on patient preference and prescriber familiarity

→ Choose DOAC based on individual factors: apixaban (5 mg BD, 2.5 mg BD if >= 2 of: age >= 80, weight <= 60 kg, creatinine >= 133 micromol/L -- ARISTOTLE trial) -- lowest GI bleed risk; rivaroxaban 20 mg OD with evening meal (ROCKET-AF) -- once daily advantage; dabigatran 150 mg BD (or 110 mg BD if >= 80 years or on verapamil -- RE-LY trial) -- reversible with idarucizumab; edoxaban 60 mg OD (or 30 mg OD if eGFR 15-50, weight <= 60 kg, or P-gp inhibitors -- ENGAGE AF trial); all superior or non-inferior to warfarin for stroke/SE prevention; start after confirming no valvular AF contraindication; educate on adherence, bleeding signs, no INR monitoring needed.

Modified Dosing Required -- Careful DOAC Selection 2–3

Modifying factors present -- DOAC selection and dose adjustment required

→ Renal function: if eGFR 30-49: apixaban or rivaroxaban preferred (dabigatran requires dose reduction to 110 mg BD; edoxaban reduce to 30 mg OD); if eGFR 15-29: apixaban or rivaroxaban only (monitor renal function 6-monthly); if eGFR < 15: consider warfarin (evidence lacking for DOACs); Drug interactions: if on amiodarone: no dose change needed with apixaban, rivaroxaban, edoxaban; dabigatran -- avoid if on strong P-gp inhibitors; if P-gp inducer (rifampicin): avoid all DOACs; Adherence: prefer once-daily DOAC (rivaroxaban or edoxaban); GI bleed history: prefer apixaban (lowest GI bleed profile) or dabigatran 110 mg BD; annual renal function monitoring; document indication and dose rationale.

High-Risk Profile -- Warfarin or Specialist Review 4–8

Multiple modifying factors -- DOAC may not be appropriate; specialist anticoagulation review

→ Haematology/cardiology anticoagulation specialist referral; if Child-Pugh B or C: warfarin preferred (all DOACs contraindicated in Child-Pugh C -- increased bleeding risk with unpredictable pharmacokinetics); if mechanical heart valve: warfarin only (DOACs contraindicated -- RE-ALIGN trial terminated early due to excess events); antiphospholipid syndrome triple-positive: warfarin only (TRAPS trial negative for rivaroxaban); if multiple interactions or high complexity: warfarin with close INR monitoring (target 2.0-3.0); anticoagulation clinic referral for warfarin initiation; Pelerin formula or 5 mg loading; target time in therapeutic range (TTR) > 65%; consider whether to anticoagulate at all if bleeding risk outweighs benefit (CHA2DS2-VASc vs HAS-BLED).

Interpretation bands for the DOAC Score. Apply clinical judgement and local guidance.

References

Yao X et al. Effectiveness and safety of dabigatran, rivaroxaban, and apixaban versus warfarin in nonvalvular atrial fibrillation. J Am Heart Assoc. 2016;5(6):e003725.
NICE NG196. Atrial fibrillation: diagnosis and management. NICE. 2021.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways

📚 MRCEM Revision

Featured in these MRCEM clinical pathways

The DOAC Score is covered in detail — with RCEM/NICE evidence base, indications and pitfalls — in the following exam-focused pathways on our sister siteReviseMRCEM.

MRCEM Primary / Intermediate / OSCE candidates: each pathway includes exam-style questions, RCEM/NICE citations, and FAQ summaries.

Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.

Score interpretation

References

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