Background The increase in elderly patients with comorbilities who are treated with direct-acting oral anticoagulants (DOACs) makes necessary an individualised pharmacotherapy follow-up during hospitalisation.

Purpose Our objective is to describe the causes of pharmaceutical interventions related to DOACs and to determite the acceptance of these interventions by physicians.

Material and methods Descriptive observational study of all patients with a DOAC prescription admitted in internal medicine from the Emergency Department (January to May 2017) and descriptive analysis of pharmaceutical interventions related to DOACs. These interventions were done through a message in the electronic prescription program. Data sources: electronic medical records and electronic prescription program. Collected data: demographic and clinical variables, laboratory data and concomitant treatments.

Results A total of 78 patients with nonvalvular atrial fibrillation treated with DOACs were included in the study, who had had 107 episodes of hospitalisation. Mean age: 79 years (54–93), 55% male. The average of chronic concomitant medications prescribed before admission was 8.8 medications (2–16). Patients were treated with apixaban (49%), rivaroxaban (37%) and dabigatran(14%). Pharmaceutical interventions were done in 49 patients to adapt anticoagulant therapy to acute episodes: 31 recommendations of DOACs’ dose reduction (52% accepted) and 18 recommendations of DOAC suspension (100% accepted). The most common cause of DOACs’ dose reduction recommendation was renal failure, followed by advanced age, active bleeding or high risk of bleeding, drug interaction and, finally, low bodyweight. Among recommendations of DOACs’ suspension, acute renal failure was the main cause, followed by active bleeding or high risk of bleeding, drug interaction, duplication of anticoagulants and liver failure. In addition, a total of 17 concomitant treatments were stopped during the study period because of the potential interactions with DOACs: benzodiazepins (eight), antiplaquet drugs (five) and others (four).

Conclusion Active surveillance is needed during the acute episodes in patients treated with DOACs. Impaired renal function, advanced age, active bleeding, pharmacodynamic and pharmacokinetic interactions, liver failure and low bodyweight are causes of overexposure to DOACs. Pharmaceutical interventions have a high rate of acceptance by physicians and can prevent adverse events.

References and/or Acknowledgements 2016 ESC Guidelines for the management of atrial fibrillation.

No conflict of interest