Anticoagulation practical checks

Scope

Use for

Outpatient anticoagulation safety checks for indication, dosing context, and monitoring.

Not for

• Major active bleeding or urgent reversal scenarios.
• Inpatient perioperative anticoagulation protocols.

Immediate actions

• Confirm indication, treatment phase, intended duration, last dose, adherence, and any planned procedure before changing anticoagulation.
• For DOAC dosing, calculate Cockcroft-Gault creatinine clearance using age, weight, and creatinine; do not substitute the laboratory-reported eGFR for drug-specific CrCl thresholds.
• Check CBC, renal trajectory, relevant liver tests, bleeding history, and interacting medicines including NSAIDs, antiplatelets, and supplements.

Red flags: escalate now

If any of these are present, stop routine steps and follow the urgency stated. Activate emergency care for instability or findings that need immediate transfer.

• Major bleeding, new neurologic deficit, or hemodynamic instability: arrange emergency assessment and communicate drug, dose, and last intake.
• Head injury while anticoagulated requires prompt ED assessment even if initially well; use emergency transport for neurologic signs or instability.
• Acute kidney injury, a major interaction, or inability to take treatment reliably requires prompt individualized advice rather than an unreviewed refill.

First-line plan

• Verify the exact agent, indication, treatment phase, renal limits, and dose against a current drug-specific guide or monograph; AF dose-reduction criteria are not interchangeable with VTE regimens.
• DOACs are contraindicated with mechanical heart valves. Seek specialist guidance for other excluded or complex indications.
• Explain bleeding precautions, agent-specific missed-dose instructions, and procedure planning. Avoid unsupervised treatment interruption or routine addition of NSAIDs/antiplatelets.

Follow-up and monitoring

• For stable long-term DOAC therapy, review indication, adherence, CBC, creatinine, and interactions at least every 6-12 months; review earlier with renal impairment, frailty, acute illness, bleeding, or changes.
• INR/aPTT do not measure DOAC intensity reliably and are not routine DOAC monitoring tests; warfarin still needs indication-specific INR monitoring.
• Use specialist/pharmacist support when renal estimates or dosing references conflict. The local dosing assistant is a cross-check, not a substitute for the current monograph.

Before the patient leaves

Return precautions you can say as written:

“If symptoms get worse, new warning signs appear, or you cannot follow the plan from this visit, seek urgent care now.”

• Point to the red flags above that apply to this patient.
• Confirm follow-up timing and where to go after hours.
• Attach a relevant handout to reinforce the plan.
• Document disposition, rationale, unresolved uncertainty, and that precautions were understood.

About this workflow

Clinical owner

Family Medicine Editorial Team

Risk tier

High

Review cadence

Every 3 months

Last reviewed

September 4, 2026AI-assisted evidence review. Clinical-owner sign-off is not recorded for this update.

Review status

Evidence current. Next review due December 4, 2026.

References

• Thrombosis Canada DOAC comparison and practical questions (opens in a new tab)
• BC Guidelines Direct oral anticoagulants (opens in a new tab)
• NICE NG232 Anticoagulation and head injury (opens in a new tab)