Background and Importance Direct acting oral anticoagulants (DOACs) are a group of drugs used for the prevention of stroke and systemic embolism in patients with atrial fibrillation. As they are considered high-risk drugs, it is important that the dosage is correctly adjusted.

Aim and Objectives To analyse pharmaceutical interventions (PI) on DOAC in electronic prescribing to hospitalised patients in a tertiary hospital and their degree of acceptance by prescribers. To detect erroneous dosage adjustments and, by means of a pharmacotherapeutic recommendation, to adapt the prescription to the patient‘s profile in order to reduce the risk of adverse effects associated with DOAC.

Material and Methods Observational, retrospective study. All patients who were prescribed a DOAC (apixaban, rivaroxaban, edoxaban and dabigatran) during their admission between 1 January 2022 and 31 December 2022 were included. The variables collected, from the ‘Unidosis Management’ module of the FarmaTools software application (v.3.0), were: date of prescription, age, sex, creatinine clearance, drug, regimen, PI performed and acceptance by the prescriber.

Results A total of 892 DOACs prescriptions were evaluated. Intervention was necessary in 53 patients (5.94%). The DOACs involved were: 29 apixaban (55%), 14 rivaroxaban (26%), nine edoxaban (17%) and one dabigatran (2%). The median age of patients undergoing PI was 85 years (75–95), with 34 men (64%). The PI performed were:

- adjustment for poor renal function in 31 patients (59%)

- adjustment for patient weight in 11 patients (20%).

- unjustified duplication of anticoagulation therapy with DOAC and low-molecular-weight heparin (LMWH) in nine patients (17%).

- modification of the dose of the DOAC prescribed on admission due to poor treatment reconciliation in one patient (2%).

- dose increase due to under-dosing in one patient (2%).

Twenty-six interventions were accepted (49%).

Conclusion and Relevance Most DOAC prescriptions are appropriate to the patient‘s situation.

In cases of error, the most frequent intervention is dose adjustment due to poor renal function, followed by weight and simultaneous prescription of DOAC and LMWH.

The overall level of acceptance of the PI is high.

Periodic weight and renal function controls are identified as points for improvement in order to assess possible dose adjustments and improve the effectiveness of treatment.

Conflict of Interest No conflict of interest.